Details for Reform Option "Training of Traditional Birth Attendants, Maharashtra"
Training of Traditional Birth Attendants (TBAs) began in Satara in 1978. The eastern region of Satara district is drought prone while parts of the western belt are particularly hilly, with many small villages unapproachable during parts of the year. In the year 2000, home deliveries accounted for 32% of all births, 11% of those were by untrained birth attendants. Two thousand dais had been trained in Satara district by March 2001, but the number of women actually working was only 862.
The need for safe delivery services was recognised as a high priority in Satara and formed one component of the Satara District Action Plan of the Sector Investment Programme (SIP) supported by the European Commission. It was also taken up under the government Reproductive and Child Health (RCH) programme. The aim was to identify the different skills required by midwives, or dais, at each level, and to train and re-train to develop those skills.
The broad strategy involved:
(i) Identification of areas where TBAs were not available
(ii) Identification and training of previously untrained birth attendants
(iii) Involvement of communities to ensure deliveries by TBAs if not institutional deliveries.
Suitable institutions - Primary Health Centres (PHCs) or private hospitals – were chosen in which to conduct the courses. Trainers, auxiliary nurse midwives (ANMs), from the selected centres were trained and a training schedule of two weeks was finalised. Taluka Health officers and Medical Officers from the relevant PHCs were called upon to verify all the deliveries conducted by TBAs and also give hands-on training.
Course components include:
(i) immediate newborn care
(ii) instruction on breast feeding practices
(iii) prompt referral to First Referral Units (FRUs) when necessary
(v) family planning advice.
Once trained, the dais are given a kit consisting of 23 items of basic equipment necessary for conducting deliveries. These include: plastic sheets, gloves, blades and scissors, kidney tray, soap, forceps, clamp, nail brush, shaving kit, disinfectant, scales for newborn weighing.
A follow-up strategy is conducted by the ANMs and, for the first two years, a concurrent evaluation of the scheme was carried out by development NGO, BAIF, appointed by the Health and Family Welfare programme in Satara. A delivery status review is given at monthly Village Health Committee meetings.
The women are paid a nominal fee of INR 100 (€1.77) on completing the training but since they are not regular health workers they are subsequently not paid a salary, although they do receive payment in kind, such as gifts of food from the family of the newborn. They remain as support to the health system rather than becoming part of it and are responsible only for deliveries. Post-partum monitoring remains the role of the anganwadi workers.
Between December 2001 and January 2005 the following results were achieved:
I. 480 dais were trained
II. Hospital deliveries increased from 68% to 84%
III. Home deliveries decreased from 32% to 16%
IV. Total deliveries by trained birth attendants increased from 89% to 97.6%
V. The infant mortality rate (IMR) was reduced from 24.1 to 18
VI. The maternal mortality rate (MMR) was reduced from 0.74 to 0.6
VII. The total fertility rate (TFR) was reduced from 2.3 to 2.1
First year (September 2001 to March 2003) grant approved: INR 4.55 Lakhs. Total expenditure: INR 608,984
Second year (April 2003 to December 2004) grant approved: INR 7.91 lakhs
Total expenditure: INR 572,830
Third year: INR 25.10 lakhs (€44,571) proposed and approved but activities yet to be started
Costs for first and second years included:
Training: INR 1300 (€23) per dai. 160 trained in first year, 137 in second year. Total (€6,822)
Kits: 1850 per kit. (120 bought in first year: INR222,000 (€3,926). 200 bought in second year: INR 370000 (€6,542)) . Total: INR 592000 (€10,472)
Delivery disposable packs: INR 20 x 7500 (€2,663)
Extra costs were incurred for developing the Dai training module and for duplication of cassettes and provision of incidentals.
Satara district, Maharashtra
One year, 10 months.
During which time workshops and meetings were conducted at district level and a District Action Plan (DAP) devised. The DAP was finalised and submitted to the government in March 2000, and finally approved by the GoI and EC-SIP members on 31st August 2001. Implementation of activities began on 1st September 2001.
Cost effective: a simple intervention aimed at women already working in RCH.
Localised: TBAs selected from areas identified as ‘low coverage’ .
Standardises care of mother and newborn: over-rules use of ‘traditional’ or superstitious treatments.
Increases access to care: in some areas TBAs are the only source of care available during pregnancy and childbirth.
Advocacy: One important role of trained dais is to encourage women to seek further skilled care if necessary.
Low literacy level of TBAs: illiteracy sometimes poses a problem during training.
No government orders are needed but Village Health Committees must be strengthened so as to create awarness of the benefits of institutional deliveries or deliveries by trained persons. Launching Behavioural Change Communication activities in villages is also integral to the success of the scheme. All deliveries in remote villages must be evaluated. ANMs must support TBAs by offering hands-on training during field visits.
Who needs to be consulted
State Family Welfare Bureau: Assistance needed to arrange training for untrained birth attendants.
Women’s self help groups: At village level, to raise awareness of dangers of using untrained birth attendants and promote safe deliveries.
Medical Officers: Needed to conduct monthly reviews of deliveries in each village.
Good. Although success in some areas depends on linking TBAs to a functioning health care system.
Chances of Replication
Good, since lack of TBAs is invariably a problem in India
Tessa Laughton, Research Consultant, ECTA, New Delhi. March 2005.