1. Skilled Birth Attendance: Successful Strategies and Lessons Learned from Deoghar district in Jharkhand, India Dr Manju Shukla, State Director, Jharkhand The Vistaar Project March 2010 Photo

2. 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..

3. 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

4. Garwa h Palamu Chatra Hazaribag h Koderm a Giridih Deogha r Dumka Sahe bganj Paku r Jamtar Dhanba d Bokar o Ranchi Khunt Seraik ela East Singhbhum West Singhbhum Simdega Gumla Loharda ga Ramga rh 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

5. Characteristics of ANMs during baselineValue 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 Deoghar Nov-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)

6. 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

7. 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

8. “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

9. 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

10. 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: - Misoprostol9%86% - Magnesium sulphate6%45% - Reagents for pathological tests17%93% - Gloves48%100% - Bleaching powder or chlorine solution73%76% N - Total69*29 # * : ANMs surveyed during baseline (Nov-Dec 2008) # : ANMs visited by the Vistaar Project staff as part of routine monitoring (As of Dec 2009)

11. Type of serviceDuring past six months Before TA (Baseline) During TA (Monitoring data) Mean deliveries attended by ANM/SBA at home 6.810.5 Mean deliveries conducted by ANM/SBA at HSC 8.614.6 Mean total deliveries attended by ANM/SBA 15.425.1 N - Total69*80 # * : ANMs surveyed during baseline (Dec 2008) # : ANMs visited by the Medical Officers as part of routine monitoring (Dec 2009) Preliminary Results Contd…

12. Services provided by ANMs among the Deliveries/ Newborns attended % ANMs Before TA (Baseline) During TA (Monitorin g data) Used Partograph in 75% or more cases1.442.4 AMTSL in all casesNo data76.8 Immediate drying and wrapping of newborn in all cases 52.280.0 Initiation of breast feeding within one hour after delivery in all cases 58.090.4 N – Total69*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%

13. Challenges Inadequate record keeping by ANMs Limited supervisory visits by medical officers to HSCs Erratic supplies

14. 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

15. For more information www.intrahealth.org; email us at: infovistaar@intrahealth.org www.intrahealth.orginfovistaar@intrahealth.org " Bound by paperwork, short on hands, sleep, and energy... nurses are rarely short on caring." - Sharon Hudacek, "A Daybook for Nurses"