Policy Brief - IIMB - Indian Institute of Management Bangalore

FKILP Briefs
The 'Fostering Knowledge-
Implementation Links' Project
(FKILP) started in July 2010 as a
joint initiative of the Centre for
Public Policy at the Indian
Institute of Management
Bangalore (IIMB) and the
Karnataka Health System
Development and Reform
Project (KHSDRP) to strengthen
the evidence base for public
health policy and programmes
in Karnataka. As one of the
outputs, the project has
launched a series of policy briefs
on critical health and health
system issues based on joint
consultations and findings from
existing and new research. The
briefs are intended to clearly
spell out the implications of
research and put forth specific
recommendations for
programme and policy.
Contributors
This policy brief was drafted by
Mridula Shankar and Dr. Srinidhi
V. with substantive and/or
editorial inputs from Prof. Gita
Sen, Aditi Iyer, Dr. Anuradha
Sreevathsa, Priya Patel, Dr. Altaf
Virani and Bhavya Reddy.
Fostering Knowledge-
Implementation Links Project
Centre for Public Policy,
Indian Institute of
Management Bangalore,
Faculty Block D, Ground Floor,
Bannerghatta Road,
Bangalore - 560 076
Tel: +91-80-26993331
Fax: +91-80-2658 2040
http://fkilp.iimb.ernet.in
Fostering Knowledge-Implementation Links Project
Identification and management of
obstetric risks and emergencies:
How prepared are primary-level
providers?
Introduction
Incentivising institutional deliveries under the
Janani Suraksha Yojana programme of the
National Rural Health Mission has positively
influenced demand. The government, in turn, has
attempted to build capacity at the primary level
by increasing human resources through the
deployment of AYUSH providers into Primary
Health Centres (PHCs), improving infrastructure
through the introduction of 24/7 facilities, and
building the capacity of medical personnel via
training. However, the question of whether and
to what extent the rise in institutional deliveries
has contributed to a reduction in maternal
deaths is insufficiently answered.
The Gender and Health Equity project has been
investigating all maternal deaths in its project
villages of Koppal district since 2004. These indepth
enquiries, which identify missed
opportunities for death prevention by health
providers, communities and families 1 , have
found that lapses at the primary care level result
in poor identification of maternal risk and/or
ineffective management of obstetric
emergencies. 2 The project therefore carried out
an exploratory qualitative study to: 1) assess
medical knowledge of first level healthcare
providers in Koppal with respect to
identification and management of obstetric
risks and complications and 2) determine
whether training in Skilled Birth Attendance
(SBA) or Emergency Obstetric Care (EmOC) is
able to improve this knowledge base.
Methodology
A purposive sample of 7 PHCs and 2 Community
Health Centres (CHCs) whose staff had not
undergone either SBA or EmOC training and 7
PHCs and 3 CHCs whose staff had been trained
were selected. Qualitative interviews were
conducted with 5 staff nurses and 4 AYUSH
doctors who received SBA training and 5 staff
nurses and 7 AYUSH doctors who did not, in
addition to 3 MBBS doctors who were trained in
EmOC and 6 who were not. Case studies
documented by the project through its verbal
autopsies were anonymised and converted into 8
clinical vignettes (5 standard cases and 3 unusual
cases), each with follow-up questions. Responses
were graded by three blinded coders based on
two criteria: the final diagnosis and the process
adopted to arrive at it. Each response was
categorised as good, poor or average with a
corresponding numerical grading of 2, 1 or 0.
Accordingly, each individual received an overall
score in the range of 0 to 16 across all cases and a
score in the range of 0 to 6 across the subset of
unusual cases. Individual assessments were then
averaged for each group to enable group level
comparisons. While our small sample precludes
the possibility of statistical testing, it nevertheless
allows us to frame policy-relevant hypotheses.
Findings
Policy Brief
The study findings (Table 1) expose certain
inadequacies in primary level provider
competencies that have implications for human
resource management and the capacity
building of medical personnel within the public
health system.
Training helps somewhat
No. 2, April 2012
Overall, staff nurses without SBA training were
least able to identify risks and obstetric
complications. In comparison, the performance of
their trained counterparts was substantially
better and on par with untrained AYUSH doctors.
Surprisingly, trained AYUSH doctors fared worse

Medical Cadre Unusual Cases All cases
(n=3; range=0-6) (n=8; range=0-16)
Staff nurses
without SBA training 0.0 3.6
Staff nurses
with SBA training 2.2 6.6
AYUSH doctors
without SBA training 1.0 7.1
AYUSH doctors
with SBA training 0.5 5.5
MBBS doctors
without EmOC training 3.7 11.0
MBBS doctors
with EmOC training 4.7 13.7
Table 1: Average group scores of responses to case vignettes
than their untrained counterparts. MBBS doctors without EmOC
training earned substantially higher scores than staff nurses and
AYUSH doctors. Those with EmOC training fared even better.
Unusual presentations of risks were poorly identified by both
trained and untrained nurses and AYUSH doctors, albeit to different
degrees. SBA training appears to have no positive impact in this
regard. Although EmOC-trained and untrained MBBS doctors
performed much better in their identification of unusual risk, they
were still below the maximum score of 6.
SBA training: Inadequate and ineffective?
The SBA training is inadequate to build the skills required for
appropriate assessment and management of obstetric risks and
complications. While this training includes a module on risk that
covers all the risk symptoms presented, trained AYUSH doctors and
nurses were unable to identify many of these symptoms,
particularly the unusual presentations relating to anaemia and
pregnancy-induced hypertension. Given its exhaustive content, the
duration of training (21 days) is inadequate, with only one-sixth of
the available time allocated to the module on risk. The quality of the
training is also variable, being dependant on the competence of the
trainers. Additionally, since these trainings are held in medical
colleges, trainees have to compete with regular students to gain
hands-on experience and exposure to cases. The absence of a
thorough post-training assessment and certification system further
reduces training rigour and the ability to evaluate the effectiveness
of the programme in improving the competency of skilled birth
attendants.
Human resource allocation and management
The study strongly suggests that AYUSH practitioners do not have
the requisite skills to identify and handle maternal risks at the
primary level. This finding is of particular relevance in districts like
Koppal where 32% of the PHCs are managed by AYUSH doctors
alone. 3 Their poor performance could be due to inadequacies in
their basic training, the lack of supportive hands-on supervision and
the absence of guidelines on their role in administering life saving
allopathic treatment during emergencies. Their current level of
training, even when enhanced by the SBA training programme, was
insufficient to enable them to be stand alone first level medical
providers.
2
The performance of EmOC-trained MBBS doctors was notably
better than their untrained counterparts. Doctors selected for this
training are usually handpicked on the basis of experience and skill,
and are promoted to specialist posts in first referral units on
completion of the training. While such a selection and deployment
process may be appropriate for human resources management, it
has the paradoxical result of removing the providers best able to
identify and handle maternal risk from primary level positions
where these skills are urgently needed.
Recommendations
1.
2.
3.
4.
Improve SBA training by introducing case-based learning
with greater focus on supervised hands-on training, specifically
geared towards risk identification and primary management of
obstetric emergencies. Instituting stringent evaluation and
certification criteria would also increase training rigour.
Make the substantially improved SBA training mandatory
for all staff nurses and AYUSH practitioners, preferably at the
start of their tenure.
Build the capacity of AYUSH doctors by formulating clear
guidelines on the role of AYUSH practitioners as first level
medical providers. A bridge course on allopathic management
of emergencies and specific protocols for the administration of
life-saving allopathic treatments can empower AYUSH
practitioners to provide essential medical care.
Train first-level MBBS doctors to further strengthen their
capacity to effectively screen, identify, manage and
appropriately refer cases of obstetric risk and complications. A
hands-on and case-based training pedagogy can serve as an
effective training model.
References
1. Iyer A., Sen G. and Sreevathsa A. (2012). "Deciphering 'Rashomon': An
approach to verbal autopsies of maternal death". (Submission under
review by Global Public Health).
2. Iyer A., Sen G., Sreevathsa A. and Varadan V. (2012). "Verbal autopsies of
maternal deaths in Koppal, Karnataka: Lessons from the grave". BMC
Proceedings 2012 6(Supplement 1): P2.
3. The Sukshema Project (2011). Maternal, Newborn and Child Health in
Koppal District. A Situational Analysis. Bangalore: Karnataka Health
Promotion Trust. Available at http://www.khpt.org/sukshema.html.
[Accessed 15 April 2012]
Suggested citation:
Fostering Knowledge-Implementation Links Project (2012). Identification and
management of obstetric risks and emergencies: How prepared are primarylevel
providers? Policy Brief No. 2. Bangalore: IIMB.