Sara Price, MAApplied Medical Anthropologist

The purpose of this research was to use the lens of Critical Medical Anthropology (CMA) to examine the effectiveness of Evidence-Based delivery practices, marketed by NGOs for use in CHCs in rural, southern Rajasthan, India.

Maternal Mortality:

India’s national maternal mortality rate (MMR):

~212 deaths per 100,000. (Office of Register General of India, 07/2011)

Rajasthan’s MMR is higher than the national average:

~318 deaths per 100,000 live births (Office of Register

General of India, 07/2011)

To improve MMR globally:

The World Health Organization has produced a set of Evidence-based Delivery practices (EBDs)

These practices are organized into three stages of labor and include:

1) Skills for conducting abdominal and pelvic examination

2) Managing all stages of labor, intra-partum care, newborn resuscitation

3) Management of post-natal complications

(Ministry of Health and Family Welfare 2010).

In-depth Interviews and Participant Observation:

Interview Participants: 11 skilled-birth attendants

working in community health centers (CHCs) in Udaipur, Banswara and Praptaghar

6 expert staff with local NGO staff training and evaluating SBA’s use of EBDs

Participant observation of: SBA trainings Evaluations of SBA performance

post-training.

17 interviews were conducted between August 2011 and November 2011

Research Location:

1) These practices were developed through a number of international non-governmental research initiatives, mostly conducted in sub-Saharan Africa. These practices were not field tested for an Indian context, nor were they made specific to the context and conditions of local factors impacting MMR and IMR.

 2) While practices such as cessation of excessive fundal pressure and administration of IM oxytocin during 2nd stage delivery have been shown to reduce MMR/IMR, many of the practices are not possible or practiced consistently by SBA staff because of infrastructural issues (such as time, patient case loads, etc.) or requests from family members to use certain practices to hasten delivery.

Ex: One SBA from Banswara commented: “We can use these practices in the labor room whenever we want. But sometimes the families don’t want the patients to get the practices…and all we can do is try to refuse their request and try to explain the process” (Interview 09/19/2011).

These quotes illustrate some of the tensions between how SBAs practice and interpret EBDs, and what the community expects from institutional delivery rooms.

4) Finally, and most importantly, despite the fact that these practices were immediately implemented into the CHC system from state and NGO initiatives, there is little to no evidence that EBDs in their current application has done anything to improve the maternal and infant health outcomes reported in southern Rajasthan.

3) The primary thrust of these practices is to encourage natural delivery, however, most patients assessing CHCs in our sample had already labored for some time at home, and were seeking care because they felt some kind of assistance or augmentation was necessary.

▪ The findings of this study conclude that while there is some medical potential in using EBDs for health, normal deliveries they should be monitored and evaluated to asses they’re relevance within the local context of rural CHCs. It may be the case that these practices need to be tailored to incorporate practices that trained staff could follow depending on the context of the labor presenting. The common causes of MMR and IMR should also be taken into account, and incorporated into these practices.

EBDs represent a unique product marketed from a globalized perspective. Yet the lack of empirical evidence that links their application to improved maternal and neo-natal health outcomes reveals them as primarily symbolic and in need of revision.

There is no evidence that EBDs have reduced maternal or infant mortality in southern Rajasthan.

The promotion of EBDs as scientifically legitimate becomes questionable then, particularly when little data supporting their effectiveness in an Indian context is available.

Furthermore, EBDs are imported from a view of the labor process articulated through a combination of humanitarian initiatives and research supported by the global north, and fuelled into the global south. In the case of EBDs, most of the data supporting the utilization of these practices was carried out through western public health initiatives conducted almost exclusively in Africa. However, NGOs often receive directives from both state and/or IGO forces in the form of financial support and programmatic implementation support if they incorporate practices, like EBDs into their programs. This begs the question: Who benefits from these programs?

Determine locally/regionally specific causes of MMR/IMR; make EBDs relevant to reducing those specific conditions/circumstances

Evaluate EBDs within a local context

Monitor their effectiveness in reducing IMR/MMR; Re-design if necessary

Utilize SBA perspective in program/policy development

The results of this study point to a significant juxtaposition between the imagined benefits of EBDs and the real barriers associated with the usefulness of these practices. Evidence-based

delivery practices in their current state have not been shown to significantly reduce MMR and/or IMR in southern Rajasthan. Evaluating, monitoring and re-designing these practices so they conform to the context and community need during delivery, provides an opportunity for re-imagining a labor room environment that incorporates strategies for

making birth safer in a way that becomes meaningful within the context of delivery in rural

southern Rajasthan.