Dai Ma and Her Contribution to Well Being of Mother, Child and Society at Large:

Ground Level Realities and EvidencesEmerging Issues and Concerns

National Consultation on

Role of Dais in NRHM

New Delhi

1 – 2 May 08

Historical Perspective • DAI MA was not pushed down from top but evolved from

within the society for centuries

• Combined traditional wisdom and knowledge and adopted into local cultural practices

• Not a mere role of giving birth to a baby, but provides all important psycho social and emotional support to mother and her family

• If properly trained and supported, the DAI MA has proved in expanding her role beyond MCH services as she has the respect, trust and acceptance in the community

in Context to Maternal Mortality

• Insufficient evidence to blame Home Deliveries by Dais as THE cause for higher and persistent MMR – Community in rural, urban, tribal and remote areas

generally opt for home delivery – but even in many of the sub center / PHC / CHC villages

or, urban slums, the situation is no differentWHY…

– because of no. of issues related to socio cultural, economic and accessibility.

– So in such a situation, Dais have been filling up this gap in their own way.

in Context to Maternal Mortality

– But on other side……. • The quality of training given to them was far from satisfactory• Most of the Public Health Institutions are not functional or not

Mother Friendly for conducting institutional delivery• No back up support readily available for referring and

managing complicated delivery cases. – Attitude of hospital staff: not welcoming at large, disrespectful

and even hostile at times – Real tragedy when ask to move from one place to other. – Many of such cases either deliver or die on the way. – This has been clearly reflected into maternal deaths audit.

– So it’s a collective failure • to provide adequate response to the needs of mothers in such

situations and• for non reduction of Maternal Mortality and Morbidity to

desired levels

Positive Evidences from Ground Regarding Contribution made by DAI’s

(If Adequately Trained and Supported)

Maternal and Child Care• Intranatal Care: Promote institutional delivery alongwith

Chirinjivi / Janani benefits – if asssured of good, mother friendly nearby centers – and in such cases, accompany as Birth Companion for

providing psycho-social support to mother OR

• If the community wishes and prefers to have HOME DELIVERY in their own, friendly environment, the DAIs are able to….– Conduct Normal Delivery cleanly and safely at home– Provide Immediate New Born Care (Asphxia Management,

Early Breast Feeding, No Bath on First Day) – Identify the delivery complications in time– Ensure prompt transfer of such cases to the nearby functional FRU

6

Referral of Maternal Cases by Referral of Maternal Cases by Front Line Workers to Base HospitalFront Line Workers to Base Hospital

at SEWA Rural, Jhagadiaat SEWA Rural, Jhagadia

499

598 610

703

914

400

500

600

700

800

900

1000

03 - 04 04-05 05-06 06-07 07-08

7

Complicated Maternal Admissions at Complicated Maternal Admissions at Base Hospital at SEWA Rural, JhagadiaBase Hospital at SEWA Rural, Jhagadia

766 756

860

1191

1308

600

700

800

900

1000

1100

1200

1300

1400

1500

03 - 04 04-05 05-06 06-07 07-08

8

Hospital Delivery (%)Hospital Delivery (%)Jhagadia Block 1.71 Lac Pop.Jhagadia Block 1.71 Lac Pop.

(Out of about 3500 Deliveries a Year) (Out of about 3500 Deliveries a Year)

23.1

27.729.4

35

45

15

20

25

30

35

40

45

50

2001-03 2004-05 2005-06 2006-07 2007-08

Only 5% in Govt. Institutions

9

Maternal Mortality Ratio (MMR)Maternal Mortality Ratio (MMR)Jhagadia Block Jhagadia Block 171,000 Pop.171,000 Pop.

(about 3500 Deliveries a Year) (about 3500 Deliveries a Year)

594

494

110

360

283

170

100

150

200

250

300

350

400

450

500

550

600

650

700

02 - 03 03 - 04 04-05 05-06 06 - 07 07-08

(4)

(12)

(16)

(19)

(10)

(6)

10

Neonatal Mortality RateNeonatal Mortality Rate (NMR)(NMR)Jhagadia Block 171,000 Pop.Jhagadia Block 171,000 Pop.

(about 3500 Deliveries a Year) (about 3500 Deliveries a Year)

47

38

27

37

23

10

15

20

25

30

35

40

45

50

55

60

03 - 04 04-05 05-06 06-07 07-08

(151)

(134)

(90)

(130)

(82)

TBA as attendant: promoting referral services

111

157 161 157148

187196

205200

187

221

0

50

100

150

200

250

May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08

# of TBA = 1930

Emergency Transport Network of Deepak Foundation

Strengthening Government Health Facilities

ANM ASHA

TBA

24 x7 SC & PHC(101 out of 158 SC)( 19 out of 39 PHCs)

Deliveries at SCs and PHCs at DCT

(2006-07 & 2007-08)

2006-07 : Total deliveries : 930 (497+433)2007-0 : Total deliveries : 2389 (873+1516) SCs : 76% rise PHCs : 250 %

53%47

47%

36%

64%

Positive Response from Govt. of Gujaratin Promoting Cause of Dais

• Helped in Registering Dai Sangathan Gujarat in June, 2005 with State NGO Cordinator as one of the members

• State Govt. passing a resolution to enhance and stranghthen the role of Dais in Oct. 2005

• State Govt. formally approving 7 member NGOs of Dai Sangathan as centers for conducting DAI Training and approved the training budget worth of Rs. 2400 per Dai for 10 days training in Nov. 05

• Participation of Govt. officials in Dai TOT organised by Dai Sangathan as well during Dai Training conducted by its NGO members and jointly signing the taining certificates

• Active Participation of Higher Level Health Officials including Health Minister in State level Dai Sammelans organised during April 05 and April 07

15

TBA Gathering at State LevelTBA Gathering at State Level

16

Govt. of Gujarat Honouring Dais and Dai Sangathan …Govt. of Gujarat Honouring Dais and Dai Sangathan …

17

Release of a Dai Training ModuleRelease of a Dai Training Module

Issues and Concerns

Public Health System/NRHM

• Not a Uniform Jacket For All, but the Region Specific Strategy to be evolvedNot a Uniform Jacket For All, but the Region Specific Strategy to be evolved• Still scope to mainstream dais in NRHM

• Relationship between dais and ASHAs• Lack of support system for dais and ASHAs• Education criteria prevents dais from becoming ASHAs

• Pressure on dais and others for institutional delivery• Unreliable data on place of delivery

• Need for council of accreditation with minimum standards

• Lack of financial remuneration for dais’ deliveries and referrals to institutions

Changing Role of Dais

• In many states, traditional roles of dais is changing

• Erosion of traditional practices such as massage, antenatal care, use of herbs and nutrition, and psychosocial support for pregnant women

• Potential to provide a range of health services

Recognition and Voice

• Varied definitions, roles and skill levels of dais

• Lack of respect for dais’ knowledge and skills

• No formal recognition (ID cards)

• Lack of organisation and empowerment of dais

Capacity Building

• Low investment in dais’ capacity building• Inappropriate training – content,

methodology, duration • Insufficient recognition and documentation

of traditional practices .• No integrate dais’ needs and realities, or

acknowledgement of their skill base• Inadequate trainer teams

Thanks for Listening to the Concerns

and Ground Realities