Policy Brief - IIMB - Indian Institute of Management Bangalore

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.