https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article Quality of Immediate Nursing Care Provided to Newborn at Maternity Teaching Hospital in Erbil City ABSTRACT INTRODUCTION The health of a nation is the wealth of the nation and today's children are tomor- row’s adults. Birth is a major challenge to the newborn to transfer successfully from intrauterine to extra uterine life. Delivery and the first few hours of life are critical period for further growth and develop- ment of the infant. Newborn baby is con- sidered to be tiny and powerless, com- pletely dependent on others for life. With- in one minute of birth the normal newborn adapts from a dependent fetal existence to an independent one *1+. Most babies are Background and objective: Quality of nursing care and competent health care providers, particularly skilled birth attendants, are essential requirements for providing care for both mothers and newborns. The current study aimed to assess quality of nursing care provided immediately after birth to newborn by nurse/midwives at Maternity Teaching Hospital in Erbil city. Methods: An observational study conducted during 2014. Samples of 25 nurse/midwives were purposively selected from nurses working at delivery room. Data were collected through the use of questionnaire format and observation checklist structured by research- er. The questionnaire format was used for interviewing nurse/midwives about (socio- demographic, professional background and nurses/midwives workload), while the check- list, which consisted of eight domains, was used for observing nurse/midwives during new- born care. A panel of experts checked the validity of the instrument when reliability was measured with computation of Pearson product moment correlation. Data were analyzed through the application of descriptive and inferential statistical tests. Results: The results revealed that the highest percentage 40% of the nurse/midwives were graduated from preparatory midwifery school, 64% of the nurse/midwives haven’t attend- ed training course about immediate neonatal care. 100% of nurse /midwives do not washed their hands before and after performing each procedure and haven’t any role in initiation of newborns breathing. There were not significant associations between overall quality of immediate nursing care and nurse/midwife's qualification, experience years and training course. Conclusion: Quality of immediate nursing care provided after birth to newborn by most of nurse/midwives was poor. The study recommended improving nurse /midwives qualifica- tions and skills, through training courses and application of a guideline for improving quali- ty of immediate neonatal care at delivery room. Keywords: Immediate nursing care; Newborn ; Delivery room. Kurdistan Mirza Jamsheer; Raparein pediatric Teaching Hospital , Erbil, Iraq. Norhan Zeki Shaker; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: norhan.zeki@nur.hmu.edu.krd) 33 Erbil Journal of Nursing & Midwifery Received: 27/8/2017 Accepted: 11/11/2017 Published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article born healthy and at term. The care they receive during the first hours, days, and weeks of life can determine whether they remain healthy or not *2+. Newborn care is very important for the proper development and healthy life of baby. It is crucial period in the lives. New born under-goes many profound changes at the movement of birth like respiratory change, thermal change and circulatory change *3+. The professional health care in general and nurses particularly play a vital role to en- sure that the new born has best possible beginning of life and the nurse must be aware of the potential problems and be alert to the infant’s changing condition and to intervene appropriately while being nec- essary *1+. In Erbil city the rate of infant mortality was 9.56 per 1000 live births in 2003 and this rate was increased to 23.9 per 1000 live births in 2011 *4+. Because nurse/midwife is the first health care provider who has direct contact with the neonate during birth and nurses will never know the quality of care they offer until it is being assessed. Therefore re- searchers thought that conducting of cur- rent study is important to assess the nurse’s performance in the delivery room based on the standards of care developed by world health organization. This study aims to assess the quality of nursing care provided immediately after birth for newborn at Maternity Teaching Hospital in Erbil City. An observational study was carried dur- ing 2014. The study conducted at delivery of Maternity Teaching Hospital (MTH) in Erbil city Kurdistan region / Iraq. The deliv- ery unit in this hospital consists of 9 rooms, first room for pelvic examination, and the second room for hepatitis cases when the reminder rooms for normal vaginal delivery and each room contain 2-3 beds and 1-2 neonate bassinette. A non-probability pur- posive sample of 25 nurse/midwives work- ing in three shifts of (morning, evening, night) at MTH recruited for the study. All nurses / midwives who were working at delivery room, giving immediate nursing care to newborn babies; delivered within 37 to 42 weeks of gestation by normal vag- inal delivery and weighing 2.5 to 3.8 kg were included in the study. While neo- nates with prematurity, birth asphyxia; congenital malformation; have been born to mothers with (pregnancy induced hy- pertension, diabetes mellitus, HIV, Hepati- tis B and Hepatitis C positive) were exclud- ed from the study. After review the related literatures and visiting the delivery room the study instru- ment were developed by researchers, in- cluding of two parts: first part was an in- terview form: A list of (10) items covered nurses/midwives' socio-demographic and working related data (age, levels of educa- tion, marital status, number of experience years in delivery rooms, interests in work- ing at delivery room, number of training course in immediate newborn care, type of working shift, number of nurses/midwives' participated in the delivery of same new- born, number of delivery nurses/midwives' performed at each shift. Second part was a checklist: for collection data about quality of immediate nursing care in delivery room, this part included the data about the nursing care of newborns after deliv- ery, which consisted of eight domains (preparation to receive the baby, initiation of breathing, thermal regulation, cord clamping, assessment ,medication, docu- mentation, initiation of breast feeding ). The ethical approval was obtained from the Ethical Committee of College of Nurs- ing after confirmation of confidentiality and anonymity of nurses / midwives. Nine experts checked the validity of the instru- ment. METHODS 34 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article Assessing quality of immediate nursing care provided to newborns at delivery room in according to nurses/midwives preparation for receiving the newborn Ta- ble 2 shows that highest mean score (2.00) was allocated to the item (Wears Gloves), the lowest mean scores (1.00) was allocat- ed to activities items like (Washes hands with soap and water to receive the baby, Wear disposable gown and checking oxy- gen supplementation. Concerning Quality of immediate nursing care for initiation of newborns breathing and thermoregulation Table 3 all the items were at the same level and all nurses/ midwives do not perform these activities. Changes and modifications were made in respect to the experts' suggestions and rec- ommendations for the questionnaire and checklist format. A pilot study was con- ducted on a sample of 5 nurses/midwives for testing the equivalence of the instru- ment. Reliability (stability) was determined and measured through computation of Pearson product moment correlation as the correlation was (0.97). The checklist items of quality of immediate nursing care in delivery room were rated and scored according to the two points type scale are used for rating 40 items and scored as (2,1) for (Yes, No) respectively. After obtaining the average of mean score of each item then the mean score of each domain calculated, followed by collection of mean score of eight domains and divid- ed upon the number of domain for obtains quality of care, these levels were consid- ered to be as a following: Good (adequate) (1.47-1.50) Fair (middle) (1.42-1.46) Poor (in adequate) (1.38-1.41). Test of signifi- cance Chi-square and p-value were used to determine the level of significance. Fre- quency and percentage mean, standard deviation, Pearson coefficient correlation (r -test) and Chi-square test were used in or- der to analyze and determine the signifi- cant association between nurses/midwives practices with demographic characteristics. In the current study results as revealed in Table 1 the mean and standard devia- tion for the nurses/midwives age was 35.32± 8.330. Concerning qualification of the nurses/midwives, the highest percent- age (40%) was graduated from the prepar- atory midwifery school. Majority (76%) of the nurses /midwives had experiences of working in delivery room from 1-10 years, and the highest percentage (64%) of the nurses/midwives had not attended any training courses. 35 RESULTS Erbil Journal of Nursing & Midwifery Table 1: Nurses/midwives socio- demographic and professional data Socio-demographic and professional data n =25 F (%) Age groups 24-34 11 (44) 35-45 11 (44) 46-56 3 (12) M ± SD 35.32± 8.330 Qualification Nursing college 2 (8) Nursing institute 8 (32) Preparatory midwifery 10 (40) Preparatory nursing 2 (8) Nursing school 3 (12) Duration of working in delivery room 1-10yr 19 (76) 11-20yr 3 (12) 21-30yr 3 (12) Training courses Attendance 0 times 16 (64) 1-5 times 4 (16) 6-11 times 5 (20) https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article Caring for newborns cord in Table 4 highest mean scores (2.00) were allocated to the following activities (place newborn on the mothers abdomen and first cord clamping) and the lowest mean scores (1.08) were allocated to the activity (Second cord clamping). 36 Table 2: Quality of immediate nursing care at delivery room for preparation to receive the newborns by nurses/midwives Erbil Journal of Nursing & Midwifery Preparation for receiving the baby n =25 YES NO Mean Score F (%) F (%) Hand washing 0 (0) 25 (100) 1.00* Wear Disposable Gown 0 (0) 25 (100) 1.00 Wears Gloves 25 (100) 0 (0) 2.00** Place the baby on clean surface 24 (96) 1 (4) 1.96 The warmer is put on 7 (28) 18 (72) 1.28 Oxygen is checked 0 (0) 25 (100) 1.00 Suction is in working condition 24 (96) 1 (4) 1.96 Suction tube is kept ready 16 (64) 9 (36) 1.64 Checking the resuscitation equipment 1 (4) 24 (96) 1.04 Bassinette is ready 10 (40) 15 (60) 1.40 Clean sheet is available 1 (4) 24 (96) 1.04 Table 3: Quality of immediate nursing care at delivery room for initiation of newborns breathing and thermoregulation by nurses/midwives * = Lowest mean score (Lowest quality of patient care) **= Highest mean score (Highest quality of patient care) Items N=25 Mean Score YES NO F (%) F (%) Initiation of newborn breathing Wipes the baby and wraps in clean cloth 0 (0) 25 (100) 1.00 Ensure airway clearance 0 (0) 25 (100) 1.00 Stimulate breathing by massaging 0 (0) 25 (100) 1.00 Thermoregulation Put newborn skin to skin contact with mother 0 (0) 25 (100) 1.00 Put the newborn under warmer 0 (0) 25 (100) 1.00 Dry the baby 0 (0) 25 (100) 1.00 Clothing the baby 0 (0) 25 (100) 1.00 Covering the head 0 (0) 25 (100) 1.00 https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article In according to newborn assessment re- sponsibility in Table 5 it demonstrates that the highest mean scores (2.00) were allo- cated to the item (Measures the weight) and the lowest mean scores (1.00) were allocated to the following activities (Apgar score performed, Apgar score recorded, Measures the length, Checks the body tem- perature, Checks for congenital abnormali- ty). Table 6 indicates that all the items were at the same level and all nurses/midwives performed these activities of newborns documentation. Furthermore in Table 7 concerning initia- tion of breastfeeding all the items were at the same level and all nurses/midwives do not perform these activities. Table 8 shows levels of overall quality of immediate nurs- ing care for newborn baby. The highest percentage (68%) of the nursing care was at the poor level, while the lowest percent- age (32 %) of nursing care was at fair level. Table 5: Quality of immediate nursing care at delivery room for newborns assessment 37 Table 4: Quality of immediate nursing care at delivery room for newborns cord clamping and mediation administration Erbil Journal of Nursing & Midwifery Items n =25 Mean Score YES NO F (%) F (%) Cord clamping Place newborn on the mothers abdomen 25 (100) 0 (0) 2.00 First cord clamping 25 (100) 0 (0) 2.00 Second cord clamping 2 (8) 23 (92) 1.08 Clamp the cord with sterile clamp 23 (92) 2 (8) 1.92 Cut the cord with sterile scissors 17 (68) 8 (32) 1.68 Mediation administration Administrating eye ointment 0 (0) 25 (100) 1.00 Vitamin k is given I.M 0 (0) 25 (100) 1.00 Assessment n =25 Mean Score YES NO F (%) F (%) Apgar score performed 0 (0) 25 (100) 1.00 Apgar score recorded 0 (0) 25 (100) 1.00 Measures the length 0 (0) 25 (100) 1.00 Measures the weight 25 (100) 0 (0) 2.00 Checks the body temperature 0 (0) 25 (100) 1.00 Checks for congenital abnormality 0 (0) 25 (100) 1.00 https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article Regarding nurses/midwives qualifica- tion and workload it shows that the highest percentages of the nurses/midwives gradu- ated from the preparatory midwifery school. This finding is consistent with a study conducted *5+ in India on nurse/ mid- wives working at delivery room and found that 32.2% of them had above secondary education. More than two third of the nurses/midwives had experiences of work- ing in delivery room from 1-10 years. In regards to the nurses attending training course about caring for newborn, the highest percentage of the nurses/midwives had no training course. This finding is in contrast to *5+ study which found that two- third of the nurses/midwives had attended refresher or training courses related to care of baby birth and resuscitation. The highest percentage of nurses/ midwives who participated in the study was working at the night shift in the deliv- ery room as most of deliveries happened at night time which needed more nurses/ midwives caring for mother and neonates. Majority of the nurses/midwives per- formed the delivery alone without help of other nurse. However, this result disagrees with American Academy of Pediatrics and American College of Obstetricians and Gy- necologists guideline *6+ which recom- mends, two nurses attending every birth, one for the mother and one for the baby. Concerning the quality of immediate nurs- ing care provided to newborns at delivery room of MTH in regarded to preparation to receive the newborn it revealed that the 38 Erbil Journal of Nursing & Midwifery Table 6: Quality of immediate nursing care at delivery room for newborns documentation Table 7: Quality of immediate nursing care at delivery room for newborns initiation of breastfeeding Table 8: Overall quality of immediate nursing care at delivery room Documentation n=25 Mean Score YES NO F (%) F (%) Identification of sex 25 (100) 0 (0) 2.00 Address of parents according to the local policy 25 (100) 0 (0) 2.00 Nurses/midwives records all information documentation 25 (100) 0 (0) 2.00 Initiation of breastfeeding n =25 Mean Score YES NO F (%) F (%) Asking for initiate breastfeeding within first hour after delivery 0 (0) 25 (100) 1.00 Placing the baby on the breast in comfortable position 0 (0) 25 (100) 1.00 Ensuring the baby has sucked for 5 – 10 minutes in each breast 0 (0) 25 (100) 1.00 Assessing the baby for positioning of the breast feeding 0 (0) 25 (100) 1.00 Overall Quality of care F (%) Poor 17 (68) Fair 8 (32) Total 25 (100) DISCUSSION https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article of the mother after delivery. Immediately after birth the newborn should be protect- ed by smooth towel but actually in delivery unit unskilled workers who take care of the baby usually perform this activity. Regarding immediate care for the cord clamp at delivery room the researcher found that all the nurses/midwives prac- ticed cord clamping appropriately. Concerning the medication care for new- born care at delivery room all nurses/ midwives did not perform these activities. The result of the present study was sup- ported by a comparative cross-sectional study done by *9+ who found that eye care was zero percent. While a study *12+ car- ried out in Canada contraries current stud- ies finding and clarified that newborns rou- tinely would receive two medications at birth: an intramuscular injection of vitamin K and an antibiotic agent for eye prophy- laxis. According to routine policy in the de- livery room of MTH the nurse/ midwives were not responsible for prescribing or giv- ing Vitamin- K and eye ointment to new- borns. Concerning the assessment of the new- born by nurses/midwives the highest mean scores were allocated to the item of meas- uring the weight, and the lowest mean scores were allocated to the following ac- tivities: Apgar score performed, Apgar score recording, measuring the length, checking the body temperature, checking for congenital abnormality. The result of the present study is consistent with the study *7+ findings, which revealed that more than 90% of infants were weighed. While it is in disagree with a purposive study *5+ conducted in India and found that only one-third of the newborns were weighed at birth, although weighing at birth was considered an essential activity to determine high risk newborn and deter- mination of extra care accordingly. Fur- thermore, according to the guidelines of highest mean score was allocated to nurs- es/midwives gloves wearing while the low- est mean score was allocated to the other activities such as hand washing , disposable gown wearing and supplementary oxygen checking .This finding is in agreement with cross sectional study *1+ carried out in Dharan hospital of Nepal at labor room on 814 normal deliveries and found that the highest percentage of the staff (99.9%) were wearing the gloves while only 24% of staff were wearing gown before receiving the newborn babies. The efficacy of gloves in preventing con- tamination of health-care workers’ hands and helping to reduce transmission of pathogens to health care providers during the process of delivery and this clarifies that gloves are unlimitedly provided to de- livery room at MTH. Concerning the immediate nursing care of newborns breathing initiation the present study found that all nurses / midwives did not perform these activities. This result dis- agrees with *7+ study, which found that nurses dried more than 90% of infants. And with another study *1+ which found that majority (100%) of nurses initiated new- borns breathing. Regarding immediate nursing care for newborns thermoregula- tion the result indicated that all nurses did not perform these activities. This finding is in agreement with *7+ study results that less than 10% only were allowed skin to- skin contact. This finding is in contrast with guidelines *8+ stating that the baby should be kept warm, by skin-to skin contact with the mother for avoiding hypothermia. While it is in disagreement with compara- tive cross-sectional study *9+ conducted in Pakistan on 30 delivery cases, which showed that the highest percentage of the thermal protection was 83.3%. According to *10+*11+ for thermal regula- tion they recommend that all neonates after birth should be placed over abdomen 39 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article percentage of the nurses/midwives levels of the nursing care was 68.0 % which indi- cated poor (inadequate) level, and the low- est percentage 32.0 % was at good (adequate) level. The findings of current study are in agree- ment with *14+ who explained that poor quality of newborn care immediately after birth in many hospitals was widely report- ed. Nurses/midwives were not informed on universal guideline of immediate new- born care that could help them to partici- pate actively in providing immediate care for the newborn. Application of the univer- sal guideline during the process of labor increases the level of care in the delivery room for the newborn and mother. Regarding quality of nursing care at de- livery room (Preparation to receive the ba- by) the researcher found that all the nurse /midwives not washed their hands before and after performing each proce- dure at delivery room, concerning the initi- ation of breathing majority of nurse/ midwives they did not performed any ac- tivity like ensuring airway clearance and stimulating breathing by massage, regard- ing thermoregulation of the newborn by nurse /midwives don’t perform it. Further- more regarding newborn assessment only newborns body weight was assessed by the nurse/midwives while they never as- sessed Apgar score, body temperature and congenital abnormality. Moreover they don’t encourage mother to initiate breastfeeding within first hour after deliv- ery. Majority of nurse/midwives overall quality of immediate nursing care for new- born at delivery room was poor. The authors reported no conflicts of in- terest. American Academy of Pediatrics and Amer- ican College of Obstetricians and Gynecol- ogists *6+ it is recommended to check Ap- gar score at 1 minute and 5 minutes after birth. Regarding the documentation by nurses/ midwives all the documentation items were at the same level and all nurses per- formed these activities. This is in agree- ment with *13+ who explained that birth date, time, sex, etc. in the delivery room should be recorded. Documentation of newborn baby is a crucial skill for nurses/ midwives at delivery room. Complete, de- tailed records are important for clinical de- cision-making, for the coordination of on- going care among providers, and as a source of quality improvement and re- search data. At delivery department in each delivery room the documentation was done completely for all newborns. Howev- er, the sense of urgency surrounding many resuscitations can make accurate, thor- ough documentation challenging. Prepara- tion can make this essential task easier. The present study showed that all the items about initiation of breast-feeding by the nurses/midwives were at the same lev- el and all nurses did not perform these ac- tivities. This finding is in disagreement with *1+ study that found breastfeeding initia- tion soon after delivery was 76.9%. The benefits of breastfeeding for the health and wellbeing of the mother and baby are well documented. World Health Organization and American Academy of Pediatrics and American College of Obste- tricians and Gynecologists *6+ recommend that breastfeeding should be initiated with- in 1 hour of birth. Early initiation of breastfeeding within 1 hour provides bene- fits for both the baby and the mother. But this practice was neglected in the delivery room of MTH by all nurses/midwives. Con- cerning levels of overall quality of immedi- ate nursing care for newborn the highest 40 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICTS OF INTEREST https://doi.org/10.15218/ejnm.2018.05 EJNM, Vol. 1, No. (1), May, 2018 Original Article *13+ DattaP. PediatricNursing.2ndedition. Jaypee Brothers Medical Ltd, New Delhi ,India. 2009; 73-74. *14+ Mike E., Stephen N., John W., Patrick M., Newton O., Philip A., et al, An intervention to improve pediatric and newborn care in Kenyan district hospitals. Un- derstanding the context, Implementation Science Journal English; licensee BMC Ltd. 2009; 4(42). Avail- able from: http://www.implementationscience.com/ *Accessed: 10th February 2014+. *1+ Shrestha M, Singh R, Upreti D. Quality of care provid- ed to newborns by nursing personnel at BP Koirala Institute of Health Sciences. Kathmandu University Medical Journal 2009; 7. 3(27): 231-232. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/20071868. *Accessed: 9th April 2014+. *2+ Beck D, Ganges F, Goldman S , Long P., Care of the Newborn Reference Manual . Washington, DC 20036. 2004; Save the Children Federation.P24-32.Available from: www.healthynewborns.com *Accessed: 10th June 2013+. *3+ Baral O, New born care practice of through mothers. A multidisciplinary journal. 2012; 2.1.P. 38-39. *4+ Ministry of Planning Kurdistan Regional Government KRG. Regional development strategy for Kurdistan region 2013-2017. 2012; P. 139. Available from: http://www.mop.krg.org/resources *Accessed: 1st August 2013+. *5+ Sarin J, Jeeva S, Geetanjli, Sheoran P. Practices of Aux- iliary Nurse Midwives re garding care of baby at birth. Nursing and Midwifery Research Journal. 2011; 7, (3) .Available from: http://medind.nic.in/nad/t11/i2/ nadt11i2p64.pdf *Accessed: 15th January 2014+. *6+ American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for prenatal care. 2007; Available from: https:// www.awhonn.org/awhonn/binary.content *Accessed: 10th February 2014+. *7+ Sobel H , Silvestre M , Mantaring J, Oliveros Y, Nyunt-U S. Immediate newborn care practices delay ther- moregulation and breastfeeding initiation. Pubmed Acta Pædiatrica. 2011; 0803–5253.available from: http://www.ncbi.nlm.nih.gov/pubmed/21375583 *Accessed: 10th February 2014+. *8+ Iradakuna C., Lambert B., Moreiras J. Resuscitation of the newborn anesthesia tutorial of the week 167. 2010; 3-11.Available from : http://www.frca.co.uk *Accessed: 8th February 2014+. *9+ Khan M, H., Khan F., R., Noman N., Hashmi G., Gul S., Ali A., et al.. Essential Newborn Care Practice In Hospi- tal Versus Home Deliveries. Gomal Journal of Medical Sciences. 2006; 4, 1. Available From: http:// www.gjms.com.pk/files *Accessed: 10th February 2014+. *10+ World Health Organization. Basic Newborn Resusci- tation: practical guide. Safe motherhood. 1999; 16. 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