Skilled-Birth Attendant(SBA) Training Program :Need of Restructuring and Strengthening to reduce IMR & MMR in Madhya Pradesh Dr. Surya Bali MD,DHHM,MHA(USA) Additional Professor Community & Family Medicine AIIMS Bhopal
Scenario of delivery in Madhya Pradesh Total reported deliveries to estimated deliveries = 67.6% (about 32 % under reporting) Total reported institutional deliveries to total annual estimated deliveries= 58.3%( around 42% under reporting at institutional level) Higher maternal and infant mortality in MP compare to country s average Source: Madhya Pradesh health management information system data for 2013-14
Strategy Increase the institutional delivery Janani Suraksha Yojana (JSY) The Yojana, launched on 12th April 2005, by the Hon ble Prime Minister, JSY is a 100 % centrally sponsored scheme
Rapid Rise in Institutional Delivery 100 90 80 70 60 50 40 30 20 10 0 91.3 81 93.8 80.8 77.4 76.4 72.2 60.3 47.1 40.8 28.7 17 DLHS 2 (2002-04) DLHS 3 (2007-08) Coverage Evaluation Survey, UNICEF (CES), 2009 NFHS 4(2015-16) http://pib.nic.in/newsite/printrelease.aspx?relid=123989
Declining trend in Maternal Mortality 400 350 300 250 200 379 44 points 335 25 points 310 33 points 277 50 points 227 150 100 2001-03 2004-06 2010-11 2011-12 2012-13
Still higher than the national average in MP Indicators India MP 12 th Plan Target MMR 178 227 100 IMR 40 54 25 U5MR 52 73 52 TFR 2.4 2.9 2.1
Comparison of MMR and IMR (MP Vs India) 250 221 227 200 178 150 100 50 54 62 40 Maternal Mortality Ratio(MMR) Infant Mortality Rate(IMR) 0 MP (SRS-14) MP (AHS 14) India(SRS - 14) http://accessh.org/wp-content/uploads/2016/03/madhya-pradesh-health- Assessment-report.compressed.pdf
Increase in the C Section at Private Percentage 30 25 19.5 21.8 25.4 20 15 10 10 5 5 0 Year 1972 Year 1979 Year 80-85 Year 1993-94 Year 1998-99 http://shodhganga.inflibnet.ac.in/bitstream/10603/15931/7/07_chapter%204.pdf
National Family Health Survey Percentage increase in C section from NFHS 1 to NFHS 4 17.2 18 16 14 12 10 8 6 4 2 0 10.2 7.1 2.9 NFHS 1992-93 NFHS 1998-99 NFHS 2005-06 NFHS 2015-16 http://jmscr.igmpublication.org/home/index.php/current-issue/3059-increasing-trend-ofcaesarean-rates-in-india-evidence-from-nfhs-4
Increasing rate of C section across India The difference in C-section delivery from NFHS- 1 to NFHS-4 shows that :- 7 states has CS rate that is more than 30%, 8 states has CS rate in between 10 percent and 20 percent and 9 states less than 10 percent
Normal Vaginal Delivery Vs Caesarean Section Delivery
Neglected Vaginal deliveries But death during normal delivery did not change much IMR and MMR still high despite of High C sections at delivery points Because Gynaecologists and Paediatricians kept focusing more on Operation theatre than labour room
Max maternal deaths occur in India http://indianexpress.com/article/ india/india-others/india-hashighest-number-of-maternaldeaths/
Maximum deaths during the time of delivery 45,000 mothers die due to causes related to childbirth every year in India.
http://www.who.int/workforcealliance/media/news/2014/end_new_born_death/en/
Where these deaths occurs? We estimated 69 400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas. Most maternal deaths were attributed to direct obstetric causes (82%). https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3893075/
Staff involved in deliveries All deliveries Normal Vaginal Deliveries Home Deliveries Institutional deliveries ANM/LHV/GNM BSc Nursing C-Section Deliveries Always Institutional Doctors (Ms OBGYN)/DGO
Training of staff who deliver babies Training Institute Medical Colleges Nursing Colleges MS OBGYN DGO BSc Nursing ANM GNM
Initial management of Mother and Babies during delivery Deliveries C Section (25%) Normal delivery (75%) Gynaecologist Paediatrician Only Nurses (ANM/GNM)
Nursing Staff Government Sector Private Sector 300 250 200 150 100 50 0 190 255 2002-03 2012-13 50 110 25 0 0 10 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 2002-03 2012-13 9735 5890 1275 220 320 0 0365 GNM BSc Nursing Post Basic Basic MSc Nursing http://www.mpinfo.org/mpinfostatic/english/articles/2013/170713lekh-16.asp
Conceptualization of SBA training program SBA training program was started in each district to provide the trained SBA for the delivery site to manage normal (uncomplicated) pregnancies, childbirth and immediate postnatal period and skilled in the identification and referral of complications in women and newborns.
Objectives of SBA Training Program To upgrade the skills of birth attendants To improve the quality of care during the delivery To make them more sensitive and responsible towards the maternal and child health Over all to minimise the IMR & MMR of the Madhya Pradesh
Evaluation Study Study design: Cross sectional Study Sampling Techniques: Multistage Simple Random Sampling Study Period: 6 Months (Oct 2014 to May 2015) Sampling Unit: Trained SBA Sample size: 335 Study setting: District hospital, CHC and PHC Study: Quantitative as well qualitative study
Randomly selected 10 Districts for the Program Evaluation
Data Collection Plan Making a sampling frame of 51 districts Madhya Pradesh: 51 Districts Random Selection of 10 districts Districts Districts Random selection of 1 CHC and 2 PHCs from one district CHC CHC Selection of two villages under one CHC PHC PHC PHC PHC Village 1 Village 2
Main findings of the Evaluation study
Finding at three level of the SBA training points Input Process Output Untrained SN,LHV,ANM Training curriculum, trainers, Infrastructure Trained SBA Beneficiaries Satisfaction Outcome Decrease MMR & IMR
Total number of SBA sampled for study 140(41.8%) Types and Number of SBA trained participants 160(47.8%) 35(10.4%) Staff Nurses ANMs LHVs
Distribution of sampled SBA 32 33 36 Selected Trained SBA from different districts 34 32 33 32 35 36 32
Knowledge of SBA(%) 90 84.3 85 83.682.9 78.6 80 80 72.5 71.372.5 71.468.6 71.4 74.3 67.5 70 63.1 60 50 40 30 20 10 0 Staff Nurse ANM LHA ANC Intra NC PNC Magt og N preg & Birth Mnmt of Complication
Skills of Trained SBA(%) 100 90 80 70 60 50 40 30 20 10 0 93.6 86.487.9 80 81.9 83.8 82.9 85.7 76.3 80 70 71.4 SN ANM LHV ANC INC and NB Resusc PNC on mother and NB Infection prevention
Key findings of Evaluation of Program SN Study points Assessment area Conclusion 1. Administrative and managerial Attitude and interest of CMHOs, CS, and DPMs Indifferent towards SBA training Not a priority program Poor supervision and monitoring 2. Training centre Classrooms and labour rooms Not well equipped Space issue Poor training ambience 3. Manpower Trainers qualification and availability 4. Logistics Supplies for teachings and training material 5. Infrastructure Residential facility Class room space Busy clinicians Not trained Less in number Non availability of training material and supplies In poor condition Not available
Recommendations
1. Specific State level SBA training Policy for Public as well as Private sector a) Provision of enabling environment for optimum performance of SBAs b) Ensuring ownership and accountability of healthcare providers especially MOs c) Advocacy of Programme in Private Institutions d) System for collection and analysis of authentic data e) Monitoring & Evaluation of the programme
2. Improving the quality of Nursing Education Improving the current nursing and midwifery course curriculum Appointment of Good quality faculties Infrastructure and teaching learning environment Strict passing out accreditation Campus interview of good quality candidates
3. Special induction training program after the joining the job One of the key study finding was Inadequate pre training knowledge of SNs LHVs & ANMs. An special induction training program should include 3 months attachments as part of pre induction training for SNs, ANMs & LHVs s to enable them to develop basic skills for providing maternal and newborn care.
4. Develop SBA Certification Policy for private delivery points Still many deliveries are conducted in private healthcare institutions through untrained staff. So it is important to train the private service providers All the facilities in the districts which provide child birth services should be registered and CMHOs should ensure that each paramedical staff, nursing staff working in labour room should be SBA trained. This will generate revenue from private sector and will certify them after successfully passing the SBA training program
5. Policy to limit the number of SBA Training Centres SN Merger of These districts Districts Nodal SBA Training Centre(17) 1 Morena,Bhind, Gwalior 3 Gwalior DH 2 Sheopur, Datia, Shivpurl 3 Shivpuri DH 3 Rajgarh, Guna, Ashok Nagar 3 Guna DH 4 Satna, Rewa, Seedhi, Singroli 4 Rewa DH 5 Umaria, Anooppur,Shahdol, 3 Shahdol DH 6 Balaghat, Mandla, Seoni 3 Mandla DH 7 Betul Chhindwada, Hoshangabad 3 Chhindwada DH 8 Katani,Narsinghpur Jabalpur, Dhindhori 4 Jabalpur DH 9 Tikamgarh, Chhatarpur, Panna 3 Chhatarpur DH 10 Sagar Vidisha Damoh 3 Sagar DH 11 Bhopal, Raisen, Sehore 3 Bhopal DH 12 Indore, Dhar, Harda 3 Indore DH 13 Neemach Mandsore Ratlam 3 Ratlam DH 14 Dewas, Ujjain,Shajapur, Agar 4 Ujjain DH 15 Khargone, Khandwa,Burhanpur 3 Khandwa DH 16 Alirajpur,Barwani,Jhabua 3 Jhabua DH Total Districts 51
Program Level Recommendations 1. State level SBA training core group/committee 2. Qualified State SBA training consultant 3. Regional Nodal SBA training Centre Manager 4. Outsourcing Trainers 5. Screening of better candidates for SBA training 6. Pre training screening of interested candidates for basic minimum knowledge and skill 7. Separate batches for SNs, ANMs and LHVs
C) Execution level Recommendation 1. Building good quality trainers pool 2. Advance annual SBA Training calendar 3. Refresher training program for trained SBA 4. Upgrade the theory class room facilities 5. Labour room facilities and hands on training 6. Ensure residential facilities
D) Post training recommendations 1. Post training follow up 2. Motivational incentives, honor, promotion better posting places etc 3. Tracking of their posting at delivery points 4. Post training refresher training time to time to sharpen and upgrade skills 5. Involving them as trainers where ever possible
E) Program Management 1. Strengthen data recording and data keeping 2. Information management system 3. Utilisation of data for supervision and monitoring 4. Evaluation of program for its effectiveness 5. Financial management 6. Anonymous feedbacks from trainees and beneficiaries