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Skilled Birth Attendance: Successful Strategies and Lessons Learned from Deoghar district in
Jharkhand, India
Dr Manju Shukla, State Director, JharkhandThe Vistaar Project
March 2010
Photo
Context
• Jharkhand state formed in 2000• 29 million population
• MMR in Jharkhand (2004-06): 312/100,000 live births
• Institutional deliveries (2007-08):• Jharkhand : 18%• Deoghar district : 16%
• Home deliveries attended by skilled personal (2007-08):• Jharkhand : 9%• Deoghar district : 8%
Contd..
Context
National Rural Health Mission (NRHM) launched: 2005- 2012
• Special focus in 18 states including Jharkhand
• Skilled Birth Attendance
• Janani Suraksha Yojana (JSY)
Govt. of India Initiatives
Government of Jharkhand requested Vistaar Project to provide Technical Assistance (TA) on Skilled Birth Attendance (SBA)
initiative in Deoghar district – Nov. 2007h
Garwah Palamu
Chatra Hazaribagh
Koderma
GiridihDeoghar
Dumka
Sahe
bgan
j
Pakur
Jamtar
Dhanbad
Bokaro
Ranchi
Khunt
Ser
aik
ela
EastSinghbhumWest
Singhbhum
Simdega
Gumla
Lohardaga
Ramgarh
Godd
a
Latehar
Deoghar district
Profile of Deoghar district Census 2001
Population (in thousands)
Percent Urban population
Percent Scheduled Caste
Percent Scheduled Tribe
Female literacy rate (7+ years)
Male literacy rate (7+ years)
1165
13.7
12.6
12.2
32.3
50.5
Profile of Deoghar district Jharkhand, India
Characteristics of ANMs during baseline Value
Mean age
Median years of work experience as ANM
Average population covered by HSC
Mean number of villages covered
Percent who stay in HSC village
Mean distance from residence to HSC in Km (N=57)
Received any training in last five years
36.4 years
17 years
5,965
12
17.4%
10.8 km
33.3%
Baseline Survey in DeogharNov-Dec. 2008
• Baseline survey conducted prior to Vistaar TA - To obtain knowledge and practices of ANMs on pregnancy, labour, delivery and newborn care
• Sample: 69 untrained ANMs & 69 Health Sub Centres (HSC)
Baseline Findings
• SBA as a job responsibility – Not a top Priority
• Record keeping on different services – Poor
• Knowledge of complications of pregnancy & delivery - Limited
• Awareness about essential newborn care services – Reasonable
• Supervisory support received – Limited
• Readiness of HSCs (infrastructure and drugs for SBA) – Fall short
Overall ANMs lacked in the knowledge & skills required for SBA and facilities also fell short
Improvement in quality of SBA
delivery (home and facility)
Reduced maternal mortality and infant
mortality
Increase in number of home and
institutional delivery by SBAs
SBA-TA Framework
Improving the quality of training
Ensuring regular &
quality supply
Supportive supervision + feedback
Motivating with
rewards & recognition
• “Training plus” approach
• Use of participatory methodologies
• Theoretical training + practice of skills
• Special focus on ‘weak’ trainees
• Follow-up/ supportive supervision by medical officers
• Use of monitoring checklist
• ANMs from better equipped HSCs trained on priority
basis
• Rotation back after six months for refresher
Key Features of TA
Progress till date…
• Govt. order for SBA-TA in Deoghar: Nov 07
• Number of master trainers trained : 22
• Number of batches trained : 11
• Batch size per SBA training : 20
• Total ANMs trained : 215
Preliminary Results
Before TA(Baseline)
During TA(Monitoring
data)
% ANMs who identify SBA activity as one of their top three job functions
25% 83%
% Medical officers visited HSC at least once during past one month
50% 60%
% HSCs with essential stock of:
- Misoprostol 9% 86%
- Magnesium sulphate 6% 45%
- Reagents for pathological tests 17% 93%
- Gloves 48% 100%
- Bleaching powder or chlorine solution 73% 76%
N - Total 69* 29#
* : ANMs surveyed during baseline (Nov-Dec 2008) # : ANMs visited by the Vistaar Project staff as part of routine monitoring (As of Dec 2009)
Type of service During past six months
Before TA(Baseline)
During TA(Monitoring
data)
Mean deliveries attended by ANM/SBA at home
6.8 10.5
Mean deliveries conducted by ANM/SBA at HSC
8.6 14.6
Mean total deliveries attended by ANM/SBA
15.4 25.1
N - Total 69* 80#
* : ANMs surveyed during baseline (Dec 2008) # : ANMs visited by the Medical Officers as part of routine monitoring (Dec 2009)
Preliminary Results
Contd…
Services provided by ANMs among the Deliveries/ Newborns attended
% ANMs
Before TA(Baseline)
During TA(Monitorin
g data)
Used Partograph in 75% or more cases 1.4 42.4
AMTSL in all cases No data 76.8
Immediate drying and wrapping of newborn in all cases
52.2 80.0
Initiation of breast feeding within one hour after delivery in all cases
58.0 90.4
N – Total 69* 125#
Preliminary Results
* : ANMs surveyed during baseline (Nov-Dec 2008) # : ANMs visited by the Medical Officer as part of routine monitoring (Apr-Dec 2009)
During Baseline:• ANMs aware of partograph: 13.0%• ANMs aware of Active Management of Third Stage of Labour (AMTSL): 31.9%
Challenges
• Inadequate record keeping by ANMs
• Limited supervisory visits by medical officers to
HSCs
• Erratic supplies
Lessons Learned
• Government ownership
• Focus on quality of master trainers
• Quality training creates demand for SBA training
• Participatory training leads to more confidence
and empowerment
• SBA programme and JSY complement each other
For more information www.intrahealth.org; email us at: [email protected]
"Bound by paperwork, short on hands, sleep, and energy... nurses are rarely short on caring."- Sharon Hudacek, "A Daybook for Nurses"