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Saving newborn lives by increasing use of skilled care in rural India

October 2008

Three women sitting next to one another, with a baby sitting on the middle one's lap

Mercila with her 7-month-old son in between the two women who helped her have a successful pregnancy and delivery: Community worker Mary Mina (left) and ANM Sangita (right).

For women like 35-year-old Mercila Hembrom in rural India, the value of skilled midwifery care is evident—both she and her son are alive and well.

For her previous five pregnancies, Mercila sought antenatal care from the local auxiliary nurse midwife (ANM) named Sangita Kumari, but had the local Dai (traditional birth attendant) deliver her at home. Sadly, she lost her last child soon after childbirth.

In this pregnancy, Mercila learned that Sangita had received a recent training on pregnancy, childbirth and newborn care as one of 37 ANMs trained by the ACCESS Program in Dumka. With support from the U.S. Agency for International Development, ACCESS and the Centre for Development and Population Activities (CEDPA) are implementing an operations research project in selected blocks of Dumka district of Jharkhand. The aim is to demonstrate that the delivery of life saving skills by ANMs—combined with behavior change communication (BCC) activities for surrounding communities—improves the access to and use of key maternal and neonatal care services, ultimately contributing to improved health outcomes and reduced morbidity and mortality of mothers and newborns. These efforts support the Government of India’s Ministry of Health and Family Welfare initiative to increase skilled attendance at birth by training ANMs, who are the health care providers closest to communities, to assist women during delivery and refer for emergency care. As a result, trained ANMs may now perform life saving skills.

Female ACM practices listening to a fetal heart beat using an anatomic model

ANMs practicing in the skills lab (above), and then providing care in the community during training (below).

Female ACM listens to the fetal heart beat during evaluation of a pregnant woman at her home

At the start of the ACCESS program in Dumka, ANMs knew little about the importance of early breastfeeding and maintenance of newborn body temperature, both essential neonatal care skills. None of the ANMs had experience with newborn resuscitation or newborn assessment, and few of the recently certified ANMs had skills in newborn immunization. ACCESS provided 12 weeks of refresher training that covered the full range of competencies and included clinical practice in communities. The two local ANM schools at Sadar District Hospital in Dumka and Mohulpahari Christian Hospital were equipped with clinical training materials, models and skills labs, and faculty and future trainers learned effective teaching skills.

At the community level, knowledge about birth preparedness and complications readiness (BP/CR) was very low. For example, only about 7% of almost 800 recent mothers surveyed in August 2007 could name three or more newborn danger signs. In these rural areas, beyond the limited numbers of locally-available, skilled health care providers, there are also other barriers to accessing skilled care—distance, transportation, cost and unsatisfactory past experiences with the public health care system.

To increase demand for maternal and newborn care, ACCESS trained and mobilized community members in more than 200 villages. These villagers then raised awareness and advocated for local action. As a result, by August 2008: 100% of these villages had a functional emergency transport system for BP/CR during pregnancy and childbirth; 69% were actively using the services provided by the ACCESS-trained ANM in their area; and over 270 community savings groups now have BP/CR savings plans. Community workers from a local nongovernmental organization work with the villages and counsel women in their homes on BP/CR, skilled care during childbirth, and postpartum and newborn care.

During Mercila's sixth pregnancy, she met a community worker, Mary Mina Hembrom, who gave her friendly advice whenever they would meet, even while fetching water. In this way, Mercila and her family learned about the importance of having a trained, skilled provider during birth, and the danger signs for mother and baby. When Mercila went into labor on a November morning, her husband called Sangita. Within an hour, Sangita arrived with her equipment and drugs, and assessed Mercila’s labor status. After a long delivery, a baby boy was born; however, he was blue and not breathing. Quickly, Sangita cleared the mucus from his mouth and nose, and dried and covered him. She then separated the baby by clamping and cutting the cord, and began resuscitating him with a bag and mask. After 20 minutes, the baby was stable and breathing normally. During this time, Sangita had also cared for Mercila, ensuring she took misoprostol and performing active management of the third stage of labor (AMTSL).

As a result of ACCESS interventions:

100% of mobilized villages have a functional emergency transport system for BP/CR;

69% of these villages are using trained ANM services; and

100% of deliveries attended by ACCESS-trained ANMs in the past month received AMTSL and the three key essentials of newborn care.

Sangita stayed with the mother and baby to provide immediate postpartum care, initiate breastfeeding, and explain the postnatal and newborn danger signs. During the next week, she came back to check on Mercila and her son three times. Mary Mina, the community worker, had also visited the mother at home and counseled her on exclusive breastfeeding and family planning.

Today, Mercila is very happy with her 7-month-old son and is thankful for the services provided by Mary Mina and Sangita. Her story highlights ACCESS's work in Dumka and illuminates the numerous opportunities to save lives with skilled birth attendants and community mobilization. ANMs, once trained, have been able to provide community-based maternal and newborn care competently and increase access to and use of these services. Moreover, women, families and communities in Dumka have quickly learned about maternal and newborn care, and have been willing and able to seek services, plan for childbirth and be prepared for complications.

Photo credit: The photos in this article were taken by CEDPA/India and are used with its permission.

The ACCESS Program is the U.S. Agency for International Development’s global program to improve maternal and newborn health. The ACCESS Program works to expand coverage, access and use of key maternal and newborn health services across a continuum of care from the household to the hospital—with the aim of making quality health services accessible for women and newborns.

Jhpiego implements the program in partnership with Save the Children, Constella Futures, the Academy for Educational Development, the American College of Nurse-Midwives and IMA World Health.

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