Abstract
BackgroundAccess to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. During implementation of the JSY, India witnessed a steep increase in the proportion of institutional deliveries-from 40% in 2004 to 73% in 2012. However, maternal mortality reduction follows a secular trend. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and therefore to a successful program outcome. We investigate, using clinical vignettes, whether birth attendants at institutions under the program are competent at providing appropriate care for obstetric complications.MethodsA facility based cross-sectional study was conducted in three districts of Madhya Pradesh (MP) province. Written case vignettes for two obstetric complications, hemorrhage and eclampsia, were administered to 233 birth attendant nurses at 73 JSY facilities. Their competence at (a) initial assessment, (b) diagnosis, and (c) making decisions on appropriate first-line care for these complications was scored.ResultsThe mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting >30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care.ConclusionsBirth attendants in the JSY facilities have low competence at EmOC provision. Hence, births in the JSY program cannot be considered to have access to competent EmOC. Urgent efforts are required to effectively increase the competence of birth attendants at managing obstetric complications in order to translate large gains in coverage of institutional delivery services under JSY into reductions in maternal mortality in Madhya Pradesh, India.
Highlights
Access to emergency obstetric care by competent staff can reduce maternal mortality
Skilled attendance at birth is associated with reduction in maternal mortality, the relationship is weak in developing countries [1] and especially in countries where the maternal mortality ratio (MMR) exceeds 200 per 100,000 live births [2]
As nurses attend the majority of deliveries under the Janani Suraksha Yojana (JSY) cash transfer program, we studied, using case vignettes, their competence at (a) initially assessing specific obstetric complications, (b) diagnosing the complication, and (c) making decisions on appropriate first-line care
Summary
Access to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and to a successful program outcome. Evidence shows that the best intra-partum care strategy is likely to be one in which women routinely choose to deliver in a health center, with midwives as the main providers, and other attendants working with them in a team. Underlying this strategy, are important principles of safety, early detection, and management of complications, including life-threatening ones [4]. Depending on the level of the facility, the management of complications would include first-line care prior to referral, or more complete management, including caesarean section, at higher-level facilities
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