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: infovistaar@intrahealth.org

"Bound by paperwork, short on hands, sleep, and energy... nurses are rarely short on caring."- Sharon Hudacek, "A Daybook for Nurses"