The State of Rajasthan has one of the highest recorded maternal mortality rates (670 per 100,000 births) in India. The situation is due to poor socio-economic conditions, non-availability of trained health personnel in rural areas and traditions surrounding marriage and childbirth. Eighty-five percent of deliveries in rural areas take place at home and most of the communities rely on a dai (traditional birth attendant) or relatives for delivery care (National Family Health Survey-2, 1998-99). Recognising the need for sensitive and affordable health care for women in small towns and rural areas, Non-Government Organisation Action Research and Training for Health (ARTH) started a Reproductive and Child Health (RCH) clinic in 1997 in Kumbhalgarh block, Rajsamand district. The goal was improvement of maternal-neonatal health and survival by providing midwives trained in safe motherhood and neonatal health interventions in a rural community. In addition, it aimed to enhance the role of panchayats (village level government) and men in the family, to contribute to safe motherhood.
The clinic served a cluster of 10 villages with a population of 11,500 and was located 5kms from the nearest Primary Healthcare Centre (PHC).
In 1999, the programme was expanded to cover 27 villages and in April 2003, one more RCH centre was started in Kadiya, Udaipur district with provision of 24-hour delivery services.
The programme area has now expanded to cover a total of 50,000 population covering 45 villages in two clusters covering Kumbhalgarh block (Rajsamand district) and Gogunda and Badgaon blocks (Udaipur district).
The programme involved:
(i) A baseline survey to establish the extent of the reproductive health needs of the community, more than half of which belong to scheduled castes and tribes. This is repeated every 3-4 years.(ii) Establishing adequate staffing at the health centres: Five nurse-midwives for two health centres who provide 24-hour delivery services. Support from doctors including specialists (gynaecologist, paediatrician and public health professionals) who visit twice a week.
Two clinic attendants who cleans the premises and linen. This support helps motivate the nurse-midwives to stay in station.
Seven health workers/ field supervisors.
Two field worker-cum-driver with motorcycle who drives the nurse-midwives to emergencies and field visits.
(iii) Community involvement: Each village has a tribal woman working as a health volunteers or Swasthya Sakhis who carry out community based education & distribution and accompany women & children to health centres if needed. They are trained to give information on nutrition, newborn & child care, maternal care, safe abortion and contraception.
(iv) Training: All the nurse-midwives were from Kerala or Rajasthan and had some basic training in nursing (ANM or GNM). In addition, they were given practical hands-on training on a range of reproductive health issues including antenatal, delivery & postnatal care, first aid for obstetric emergencies; reversible contraception and neonatal and child care; with use of standard guidelines and protocols adapted to Indian setting.
(v) In-house Services: Since October 1999, the nurse-midwives have been providing 24-hour delivery and obstetric first aid services. In addition, outpatient services are provided on 6 days a week, while the services by doctors (gynaecologists and paediatricians) continued on two fixed days a week.
The clinic provided the following services – ANC, PNC, delivery services, reversible contraception, first trimester abortion, management of Reproductive Tract Infections (RTIs), Sexually Transmitted Diseases (STDs), gynaecological conditions, and Child Health services including immunization & treatment of sick children. The clinic provided subsidies to poor women for obstetric emergencies. When a nurse identifies a problem that is beyond her competence, she stabilizes the patient, arrange transport and accompany her to the referral hospital in city. She also negotiated admission and start of treatment at the referral hospital.
(vi) Outreach services: In addition, once-a-month village clinics are held by the nurse-midwives with support from field workers and volunteers on pre-designated days. The village clinics are held in one room of an Anganwadi or the house of ARTH’s volunteers. The services provided at village clinic are: antenatal care, counselling, pregnancy confirmation, contraception (oral pills, condoms, follow-up doses of DMPA (this means that if first dose had been given after proper screening under the supervision of a doctor, then subsequent doses of DMPA could be given by nurse midwives), and treatment of minor ailments and childhood illnesses.
(vii) Family planning: As a part of its outreach programme ARTH has been running a Community-based Education and Distribution (CBED) programme covering a range of contraceptives. Women volunteers and field workers of ARTH have been distributing condoms and oral contraceptives within the community. They refer those who want a copper-T (CuT 380A or CuT 200B) or injectable (DMPA) to the RCH centre. In the clinic, all women are given contraception counselling. It provides reversible methods of contraception.
(viii) Referral and transportation: Referral links have been developed with the medical college and a few private diagnostic facilities in Udaipur city. Three local jeep taxis provide quick transport of nurse-midwives accompanying women needing referral to the hospital in Udaipur, at fixed cost.
(ix) Service Charge: There is no consultation charge, while the drugs are provided at no profit basis (the drugs are bought at wholesale rate). All services are subsidized, and the subsidy is greater for tribal patients. Services are charged much below the market rate for example delivery is charged at INR 100 (€ 1.74) and INR 200 (€ 3.44) respectively for tribal and other castes women, ‘inclusive of all drugs and supplies’.
Recently, ARTH has also promoted the development of health funds (Swasthya Kosh) through 20 self help groups in its field area. The health funds range from Rupees 2000-3000 and each has 25% contribution from members of SHG and 75% contribution from ARTH. The members of SHG are required to save every month INR 5 (€ 0.093) to INR 10 (€ 0.186959).The fund is to be used exclusively for meeting the emergency health needs of women and children.
(x) Drug supply: A revolving “clinic fund” was established, to procure drugs and supplies, which were sold at a not-for-profit basis. Medicines are procured from whole seller at lowest rates and are sold by adding 10% to cost of procuring it by ARTH. The cost of medicines is displayed in the clinic.
(xi) Information, Education and Communication activities: IEC activities are carried out through group meetings of women and adolescents, including SHG meetings, where pictorial booklets are used. In addition, individual counselling of pregnant women and their husbands is also carried out in the villages. Delivery services are publicized through pamphlets distributed by field workers in the project villages and through personal interaction with those that visited the health centre.
Both the centres started with outpatient clinics, where doctors provided the services twice a week. The first centre was upgraded to Safe Motherhood Centre (SMC) with 24 hour services in year 1999, while the second centre started providing 24 hour services in year 2003. ARTH also gets supplies from the public health system – ORS packets, iron and folic acid tablets and vaccines. It maintains registers of outpatient treatment, deliveries, contraceptives etc. Safe abortion services were started in the first centre in 1999 after two years wait for a registration certificate for the facility, and in year 2005 in the second centre. Because electricity is a problem in these areas, manual vacuum aspiration (MVA) technique and medical abortion are used for providing safe abortion.
1. It took a few months before community started utilizing delivery services - only 7 deliveries were conducted in the clinic in first six months.
However through continuous interaction of the nurse midwives with the community, the involvement of panchayats and the trust built by the competence of the nurse midwives that women began to use the clinic.
In 2004-05, the nurse-midwives attended 311 deliveries, out of which 36 women needed referral for maternal or foetal complications.
As their confidence grew, the proportion of women needing referral declined -- in 2000-01, 20% women were referred, but in 2004-5, only 11% were referred. Nurse midwives have also assisted in delivering breech babies.
2. Nurse midwives have also attended to 30 cases of obstetric emergencies in year 2004-05 who came with emergencies related to antenatal or postpartum period or abortion.
3. Nearly 2266 antenatal checkups have taken place last year in RCH centres or field clinics.
4. Nearly 8000 clients have been seen by the 2 health centres in last year with various needs – 94% of them were for reproductive or child health needs.
5. In year 2004-05, 221 women utilized copper-T services, and 104 women accepted DMPA injections on an average per month.
6. The proportion of women delivered by skilled attendants or those receiving ANC has shown significant increase, especially for women of tribal and backward communities.