Problem: What problem is this project trying to address?
Historically, most child births in India were home deliveries facilitated by traditional midwives –dais. The state, both before and after independence, sought to train and build the skills of healthcare workers and midwives by offering different training programs, diplomas and courses, while continuing to support dais attending home births. From a skill oriented one-year diploma in midwifery in 1947, to the two years auxiliary nursing and midwifery (ANM) course, and finally to the 18-month multipurpose health worker training in 1975, midwifery skills of peripheral workers have undergone several changes, before becoming and are watered down to a few skills. The multipurpose healthcare workers are now trained as generalists and provide maternal care as only one of their many functions. Research shows that the curriculum for Auxiliary Nurse Midwives (ANMs) falls short on basic midwifery competencies, covering only 20-30% of what is required by International Confederation of Midwives (ICM).This has had an adverse effect on the health of mothers and children.
The persistence of high maternal mortality rates drove the Indian government to launching a policy incentivizing institutional deliveries (through monetary incentives, transport facility to hospitals, motivation through social change agents in all villages called ASHAs, etc.). This policy drove large numbers of women into government and private health facilities for care during the last decade. However this policy, though oriented towards safe and secure birth, exposed the inability of the existing healthcare system to respond to the growing demand for safe birthing care. India sees about 70,000 babies being born per day, or one child per 1.25 seconds.
The lack of adequate obstetricians and gynecologists, results in doctors only spending an average time of 2.5 minutes per pregnant woman.
In these conditions, women are subject to emotional and even physical abuse and irrational use of technology to hasten the birthing process. Thus, instead of impacting positive birth experience, the move to institutions this has an adverse affect on maternal and child health, in some cases, even leading to maternal mortality due to unwarranted intervention.
There is a growing recognition that primary health care centers (PHC) are not serving the vital function of maternal and childcare due to the lack of qualified obstetricians. There is also an argument arising from experiences worldwide that normal births do not require the presence of obstetricians all the time. What is essential is an observant provider with skills to recognize complications, and a facility that will respond immediately on arrival of a complicated mother or baby. There is a need for a separate cadre of skilled professionals with training in medical and human skills to facilitate a safe and dignified birthing experience. Midwifery training, practice, regulation and standard setting processes are undergoing rapid changes in neighboring countries. The experiences of other South Asian countries like Bangladesh show that nurses who are specifically trained with technical and soft skills of birthing and refer complicated cases to doctors, can bring down MMR by 68% (study by Tinker & Koblinsky).
Indian healthcare professionals need better skills, infrastructure, regulation and monitoring and mentoring. Training needs to move from textbooks to allow for skill practice and stimulating clinical scenarios. There is also an urgent need to instill soft skills related to birthing. A systematic review by USAID International (2010) has revealed that disrespectful care and abuse exist in maternity service delivery and can be an important obstacle to the desire and willingness of women to access the care they may need around childbearing. Mothers are often neglected, left exposed and not treated with respect and dignity. This has led not only to reduction in the quality of service for birthing, but also has affected the places where actual birthing takes place, reducing them into a room to experience pain and trauma rather than the joy of bringing to the world a new bornhuman being. Regulatory bodies like the Indian Nursing Council have to enact regulations to enable specialist midwives to redirect their practice to meet changing healthcare needs. For example, the midwives should be licensed to undertake essential life saving emergency care measures when necessary.
Solution: What is the proposed solution? Please be specific!
Dr Prakasamma has drawn up a plan to bridge the gap in childbirth services created by the discontinuation of support to traditional midwives or dais on one hand, and the acute shortage in obstetricians, on the other. She has designed a new role for general nurses working in hospitals and Auxiliary Nurse Midwives working in peripheral health centres in India. The new cadre of professionals will combine medical knowledge and humane caring to make birthing a safe and joyful harmonious experience for mothers and their babies. She has developed models for a dedicated cadre of midwives in all maternity units. The result of her advocacy is a new specialization course in midwifery called “Nurse Practitioner in Midwifery” offered by the Indian Nursing Council.
Based on her research in several states in India, Dr. Prakasamma highlighted the need for labs for teaching midwifery and newborn care skills in all training institutions. She designed a prototype lab at her Institute -ANSWERS - and helped four state governments to establish such labs at the Centres for Advanced Midwifery Training that she assisted to develop. The concept of the ‘Skills Labs’ has now been adopted by the Government of India and such labs are now being established across the Country.
Dr. Prakasamma has established a Birthing Temple, a physical space, to demonstrate how birthing is a multidimensional process where the mother and baby are normal human beings at a very special moment in their existence. The Birthing Temple combines the focus on technical safety with the values of psycho-social and spiritual caring. She has also advocated for “labour room” reforms” reforms across the Country such as reducing the height and expanding the width of the table to make it more comfortable for women.
Dr. Prakasamma founded the Society of Midwives, India (SOMI) to advocate for an independent cadre of midwives (NPM) nationally. Now a national body with more than 7500 members, SOMI hasSOMI has already influenced practices and built opinion around skilled birth attendance in different states – West Bengal, Odisha, Gujarat, Andhra Pradesh.