RAJIV GANDHI UNIVERSITY OF THE HEALTH SCIENCES,
KARNATAKA, BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
01 / NAME OF THE CANDIDATE AND ADDRESS / Mrs.SHAHNAS.MI YEAR MSc NURSING
RAJEEV COLLEGEOF NURSING,
K R PURAM HASSAN
02 / NAME OF THE
INSTITUTION / RAJEEV COLLEGE OF NURSING,
K R PURAM.
HASSAN.
03 / COURSE OF THE STUDY AND SUBJECT / MASTER OF SCIENCE IN NURSING,
OBSTETRICS AND GYNAECOLOGICAL NURSING
04 / DATE OF ADMISSION TO COURSE / 8/07/2011
05 / TITLE OF THE TOPIC / EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON KNOWLEDGE REGARDING HOME BASED NEW BORN CARE.
05 / STATEMENT OF THE PROBLEM /
“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING HOME BASED NEWBORN CARE AMONG ASHA WORKERS IN SELECTED PHCs AT HASSAN”
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION.
“ If one feels the need of something grand,something infinit,something that makes one feel aware of god, one need not go far to find it. I think that I see something deeper,more infinit,more external than the ocean in the expression of the eyes of a little baby when it wakes in the morning and coos or laugh because it sees the sunshining on its cradle.”
-Vincent Van Gogh
Anewbornorbabyis the very youngoffspring of a human or other mammal. The newborn orneonate(from Latin,neonates , newborn) period is defined as beginning at birth and lasting through the 28th day following birth which includesprematureinfants, postmature infants andfull term newborns. The terminfantis derived from theLatinwordinfants, meaning "unable to speak" or "speechless." It is typically applied to children between the ages of 1 month and 12 months; however, definitions vary between birth and 3 years of age. "Infant" is also a legal term referring to any child under the age of legal adulthood. The averagebirth weightof a full-term newborn is approximately 3.2kg and is typically in the range of 2.7–4.6kg. The average total body length is 14–20inches (35.6–50.8cm), although premature newborns may be much smaller. TheApgar scoreis a measure of a newborn's transition from theuterus during the first minutes after birth.1
Newborn care is of immense importance for the proper development and healthy life of a baby. Although childhood and infant mortality in South Asia has reduced substantially during the last decade, the rate of neonatal mortality is still high. According to one source, 60% of all neonatal deaths and 68% of the world’s burden of perinatal deaths occur in Asia. Further, although 70% of infant deaths occur during the first month of life, the policy-makers and health professionals in developing countries, until recently, neglected newborn care. Infants cry as a form of basic instinctive communication. A crying infant may be trying to express a variety of feelings including hunger, discomfort, overstimulation, boredom, wanting something, or loneliness.Breastfeeding is the recommended method of feeding by all major infant health organizations.If breastfeeding is not possible or desired, bottle feeding is done with expressed breast-milk or withinfant formula. Infants are born with a sucking reflex allowing them to extract the milk from thenipplesof the breasts or the nipple of the baby bottle, as well as an instinctive behaviour known asrootingwith which they seek out the nipple. Weaning is the feeding stage for older infants almost toddlers. It is a process where solid foods are introduced into the diet and is slowly replaced in exchange of milk. Children need more sleep than adults up to 18 hours for newborn babies. Until babies learn to walk, they are carried in the arms, held in slings or baby carriers, or transported in baby carriages or strollers.2
Newborn care often receives less-than optimum attention. Although, over the past 25 years, child survival programs have helped reduce the death rate among children under age 5.The biggest impact has been on reducing mortality from diseases that affect infants and children more than 1 month old. As a result, the vast majority of infant deaths occur during the first month of life, when a child’s risk of death is nearly 15 times greater than at any other time before his or her first birth.Unlike infant and under five mortality rates, reductions in neonatal mortality have been less in the developing countries.2
Proper nutrition and hygiene are the answers in many cases,while other deaths can be prevented by using widely available vaccines and medications to prevent and treat infections, by having skilled health care at hand during and after delivery, by recognizing and promptly treating obstetric complications, by keeping the baby warm and the umbilical cord clean, and by improving breastfeeding.2
Traditional care practices at home and in the community inevitably affect maternal andnewborn health. In the countries of South Asia women often have many children who are closely spaced.Women maintain their full workload during pregnancy and restrict their diet due to fear of delivering a big baby. Lack of understanding of the urgency attached to newborn illnesses or obstetric emergencies, traditions of seclusion of mother and newborn, fatalistic outlook, belief in evil sprits, and lack of family finances to pay for care and transport also cause delay in deciding to seek care.1
6.2. NEED FOR STUDY.
The average infant mortality rate worldwide has dropped from 95 per1,000 live births,60 per 1,000 live births. But the progress in reducing perinatal and neonatal mortality in South Asia region has been distressingly low despite improvement in childhood and infant mortality rates in the last two decades. The issues of perinatal and newborn infant health, therefore, require focused attention in South Asia.2
According to WHO about 98% of newborn deaths occur in developing countries, where most newborns deaths occur at home. A cross-sectional survey carried out in an immunisation clinics of western Nepal during 2006 reveals that,out of 240 mothers interviewed,140(58.3%) were planned home deliveries and 100(41.7%) were unplanned.Only 46 (16.2%) women had used a clean home delivery kit and only 92 (38.3%) birth attendants had washed their hands. The umbilical cord was cut after expulsion of placenta in 154 (64.2%) deliveries and cord was cut using a new/boiled blade in 217 (90.4%) deliveries.Birth place was heated throughout the delivery in 88 (64.2%) deliveries. Only 100 (45.8%) newborns were wrapped within 10 minutes and 233 (97.1%) were wrapped within 30 minutes.Sixteen (10.8%) mothers did not feed colostrum to their babies. Main reasons cited for delivering at home were 'preference' (25.7%), 'ease and convenience' (21.4%) for planned deliveries while 'precipitate labour' (51%), 'lack of transportation' (18%) and 'lack of escort' during labour (11%) were cited for the unplanned ones.3
A cross-sectional study conducted to the knowledge and practices related to newborn care in urban slums of Lucknowcity, UP, and to identify critical behaviours, practices, and barriers that influence the survival of newborns.Datas from 524 women were analyzed and showed that about half of the deliveries took place at home. Majority (77.1%) of the mothers believed that baby should be bathed with warm water and dried with clean cloth and 79.7% mothers practiced it. Only 36.6% mothers initiated breast-feeding within 1 h of birth and 30.2% initiated after 1 day and few not.In majority of cases, correct knowledge and correct practices regarding newborn care were lacking among mothers and this should be promoted through improved coverage with existing health services.4
A study was conducted in Kengeri, rural Bangalore, Karnataka.A total of 90% of the deliveries were hospital deliveries and 10% were home deliveries. The care provided during the home deliveries was mainly given by an untrained birth attendant (40%). A household knife (50%) was used to cut the umbilical cord in five home deliveries. In both in-hospital and home deliveries, nothing was applied for umbilical cord dressing (67%). Talcum powder (10%) and turmeric was used by some mothers for cord dressing. A total of 16% of the mothers still practiced branding of the child for illness. A total of 93% of the children received all vaccinations needed according to the national immunization schedule.5
ASHA worker’s knowledge is one of the crucial aspects of health systems to improve the coverage of community-based newborn health care programmes as well as adherence to essential newborn care practices at the household level. ASHA workers needs to improve their knowledge level, so the evaluator selected the STP about home based newborn care to improve the knowledge of ASHA workers.
6.3 REVIEW OF LITERATURE
Review ofliterature is divided into four parts:
6.3.1Review of literature related toprevalence and incidence of newborn complications
6.3.2Review of literature related to new born care.
6.3.3Review of literature related tohome based newborn care.
6.3.4 Review of literature related to knowledge of new born care among ASHA workers.
6.3.1Review of literature related to prevalence and incidence of newborn complications
A retrospective study is to evaluate the obstetric management and perinatal outcome of extreme prematurity (22-27 weeks) in a busy teaching hospital between April 2004 and March 2005. A total of 57 babies were delivered in 49 women representing 0.9% of total births. A total of 67% of babies were transferred to the NICU and the survival rate for those who were admitted to the NICU was 47%. The overall survival rate for all births at hospital discharge was 32%. Caesarean section was carried out in 32% of the 49 mothers. The overall survival at discharge in these babies was 50%. Only 12.5% of babies delivered by caesarean section at less than 27 weeks survived as compared with 70% survival rate at 27 weeks. There was no survival among babies delivered by caesarean section below 26 weeks. Gestational age of the neonate was the single most important parameter, even after adjusting for other parameters like birth weight, sex of baby and maternal chorioamnionitis. Birth weight was an independent risk factor for survival, with a birth weight of 900 g; the survival rate was significantly higher. Hypertensive disorder was the most common maternal medicalcomplicationand responsible for 7/16 caesarean sections. The study highlighted the importance of the multidisciplinary team management and the involvement of parents in the decision regarding management of these very pre-term babies, during labour and after delivery.6
A study conducted all male neonates presented for circumcision at theUniversity of Benin Teaching Hospital, Benin City, Nigeria. Those diagnosed with hydrocele were recruited and followed up in a surgical outpatient clinic for 2 years. The number of cases of spontaneous resolution and age at which this occurred were documented on a structured pro forma. As a result a total of 2715 neonates were circumcised and 128 (4.7%) were diagnosed with 163 cases of hydrocele, while 27 cases in 25 (0.9%) children failed to resolve at the age of 2 years. Neonatal hydrocele was bilateral in 112 (68.7%), and there were 20 (12.3%) right and 31 (19.0%) left. Among those with hydrocele, 28.1% were delivered preterm and resolution was spontaneous in many of them, with no observed significant statistical difference to those delivered full term. Of the 163 hydrocele cases, 136 (83.4%) resolved spontaneously by age 18 months with peak resolution at 4-6 months.Neonates with congenital hydrocele should be observed for spontaneous resolution for at least 18 months before being subjected to surgery.7
On April 24, 2007, abortion before 12 weeks became legal in Mexico City. The arguments for this decision were: diminish the maternal morbidity and mortality, avoid a "severe health problem" and accomplish the women's physical, mental and social.Retrospective study realized by bibliographic search of electronic data basis and Internet portals of interested groups.Mexico is considered by the WHO, one of the countries in the world with low maternal mortality rates (<100/100,000 live births).The main causes are: preeclampsia-eclampsia,pregnancyrelatedhemorrhage,complicationsof pregnancy, delivery and puerperium, and other causes (92.2 to 93.1%). In 2007, the Health Services of Mexico City reported 11 deaths (0.03% of the total maternal deaths) associated with "non-spontaneous abortion". In the hospitals of the Mexican Institute of Social Security, maternal deaths as consequence of induced abortions were, approximately, three every year. The evidences used as arguments in favour of abortion come from studies performed in Sub-Saharan African countries, which do not apply to Mexico.The scientific evidences show that induced abortion has important psychological sequels in women, a higher frequency of illegal drug abuse, alcoholism, child abuse, low birth weight in the following pregnancy, greater risk of subsequent miscarriage and greater mortality rate.There are no scientific evidences to support the arguments used for the legal approval of abortion in Mexico City.8
6.3.2 Review of literature related to new born care.
A study was conducted in PHC that is attached to medical college in Kengeri, rural Bangalore, Karnataka, to describe the breastfeeding practices prevalent in rural areas.The objective of this study was to describe the breastfeeding and newborn care practices in rural areas and the secondary objective was to describe the factors affecting the initiation and duration of breastfeeding.Mothers with children who were 9 months old who came to the PHC for measles vaccination were included in the study and data was collected using the pre-tested questionnaire on breastfeeding and newborn practices. Study shows 97% of the mothers initiated breastfeeding, 19% used pre lacteal feeds, 90% had hospital deliveries and 10% had home deliveries, and 50% used a house knife to cut the umbilical cord among home deliveries.
A study was conducted in three rural districts in Bangladesh. The aim of this study was to examine the prevalence of maternal andnewborn-carepractices among women reporting a birth in the previous year in three districts in different divisions of Bangladesh. 6,785 women, who had delivered anewborn infant, across three districts in Bangladesh, were interviewed. Overall, less than half of the women received any antenatalcare, and 11% received a minimum of four check-ups. Only 18% took iron tablets for at least four months during pregnancy. Over 90% of the 6,785 deliveries took place at home, and only 11% were attended either by a doctor or by a nurse. The mothers reported three key hygienic practices in 54% of deliveries: attendants washing their hands with soap and boiling cord-tie and blade for cutting the cord. 44% of the 6,785 infants were bathed immediately after delivery, and 42% were given colostrum as their first food. The results suggest that maternal andnewborn-careremains a cause of concern in rural Bangladesh. Short term policies to promote healthy behaviour in the home are needed, in addition to the long term goal of skilled birth attendance.9
WHO presented an overview of the activities for improving newborn health in the south east Asia region(SEAR),first highlighting the regional situation on maternal and newborn health,as maternal and newborn health are inseparable. In five countries of the region the proportion of delivaries assisted by skilled attendant is below 50%,while the global target is a universal coverage (at least80%) by 2015.The regional estimate of maternal mortality ratio and neonatal mortality rate are still very high, contributing to a third of global maternal and neonatal deaths. The proportion of neonatal death contributes to 45% of under 5 deaths,it suggests that the corrent level of neonatal deaths needs to be atleast halved in order to achieve Millenium development goal. The objective of this study was the basic perinatal education to increase parental knowledge of neonatal illnesses (such as respiratory distress, sepsis, complications of prematurity) could be a feasible way to reduce high neonatal mortality rates in limited-resource nurseries. To assess the efficacy of antenatal education in increasing mothers' knowledge of basic newborn care in a limited-resource nursery, and to determine whether the knowledge is retained postpartum. 10
In March to April 2008, WHO implemented a 10-min educational program on basic neonatal care for women receiving prenatal care. The educational intervention was a structured, face-to-face interactive module taught by using pictographic and written materials about temperature control, umbilical cord care and signs of neonatal illness. Assessed knowledge before and immediately after the module using a standardized interview tool.The result was,out of recruited 101 women (average age=26.3 years), the knowledge of neonatal care increased by 10% on immediate post test, especially regarding knowledge of umbilical cord care and temperature control (normal temperature ranges, thermometer use). Maternal education (P=0.025) and previous births (P=0.037) correlated positively with higher pretest scores. Higher maternal education correlated with higher post test scores.11
6.3.3. Review of literature related to home based newborn care
A study was conducted in the community involving mothers who had given birth in two hospitals in the Puttalam district in Sri Lanka. The intervention was a 4-day training programme and primarily aimed at increasing knowledge and skills of essential newborn care( ENC) among health care providers in the maternity units of these hospitals. Before the intervention, 144 mother–newborn pairs were followed-up and interviewed at their households within 28–35 days of delivery. Three months after the intervention, 150 mother–newborn pairs were interviewed at home. Results revealed that there was a significant improvement in umbilical cord care practices at home following the intervention. Application of ‘surgical spirit’ on umbilical cord has declined from 71.5% in the pre-intervention to 45.3% in the post-intervention samples. Pre-intervention breastfeeding rates were high, and there wasn't any further improvement in the post-intervention. There was a 35% reduction in the proportion of newborns who developed any undesirable health events at home.12