The Changing Role of Auxiliary Nurse Midwife (ANM) in India: Implications for Maternal and Child Health (MCH)

The world’s democracy and its second most populous country, India was the first developing country to have a national family planning program and has implemented countrywide reproductive health programs such as RCH I. India’s primary health care and the family planning programs have come a long way after the independence in improving health indicators in general, yet it has high material and under five mortality rates. The country has developed an extensive network of primary health centers and sub- to provide basic medical care to huge (80%) rural population. In the rural health care system, the ANM is the key field level functionary who interacts directly with the community and has been the central focus of all the reproductive child health programs. In contrast with resident ANM of sixties who was providing delivery and basic curative services to the community, today’s commuting multi purpose worker is more involved in family planning and preventive services. This has implications on the implementation and coutcomes of maternal health programs in rural India. The midwifery role of the ANM should be restored if the goal of dcreasing maternal mortality has to be met. The priority will have to change from family planning immunization to comprehensive reproductive health including maternal and neonatal care. These changes will require sustained and careful planning/resource allocation. Increasing resources along with systemic reforms will improve health status for women and children who are the focus of Reproductive Child Health programs.

Implementation of Janani Suraksha Yojana and other maternal health policies in two Indian states: Predictors of maternal health service utilization among poor rural women

Poor, rural women in India contribute disproportionately to the nation's high maternal mortality ratio. In response to this problem, the Indian government launched a conditional cash transfer scheme, "Janani Suraksha Yojana (JSY)," in 2005 to increase poor women's access to maternal health care. The state of Tamil Nadu reorganized public health system resources and the state of Gujarat contracted with private providers to implement the scheme in rural areas. This study investigated the role of JSY/government assistance, and other health care sector and household factors in predicting poor, rural women's utilization of maternal health services in the two states. Health care sector factors included receipt of JSY payment, availability of a primary health center with round-the-clock services, and connection to a health facility by an all-weather road. Household factors included maternal education, paternal education, age at first birth and parity. Use of four maternal health care services was examined: adequate antenatal care, institutional delivery, private facility delivery and Cesarean section. State findings were compared and contextualized by examining health polices/practices and health infrastructure within each state. The study employed secondary data analyses using District Level Household Survey (DLHS)-3 data, with a sample of 2,267 rural women from the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between identified factors and maternal health care utilization in the two target states. Overall, Tamil women had better access to maternal health care services than Gujarati women. JSY payment predicted use of private facility deliveries in Gujarat, which incentivized use of private providers, but not institutional deliveries in Tamil Nadu where women also received cash regardless of the place of delivery. JSY payment did not predict adequate antenatal care, which was not incentivized. Access to an all-weather road predicted institutional deliveries in both states and adequate antenatal care by Tamil women. Maternal education was a significant predictor of maternal health services utilization in Tamil Nadu, while paternal education predicted such usage in Gujarat. Parity significantly predicted poor, rural women's use of all services. Implications of the findings for strengthening conditional cash transfer schemes and improving maternal health care services are discussed

Strengthening Midwifery Services in India based on lessons learnt from Sweden and Sri Lanka

Objective: The objective of the paper is to know how India can strengthen midwifery services to reduce maternal mortality based on the lessons learnt from Sweden and Sri Lanka. Method: The paper is based mainly on the literature review, field visit to Sweden and interaction with maternal health experts from Sweden and Sri Lanka. Conclusion: High maternal mortality in India is due to absence of skilled attendance at the time of delivery and poor post-natal care. Seventy percent Indian population is rural and it is not possible to have doctors for all births. Adopting evidence-based interventions such as developing a skilled cadre of locally available midwives backed up by efficient referral and emergency obstetric care services like Sweden and Sri Lanka will help India achieve the goal of reducing maternal mortality with the existing resources. Analysis also shows that establishing quality training, independent regulating body and standardizing midwifery practices in India requires sustained efforts from government, professionals and society, and reorganization of health systems. Creating the scope for career advancement will help to improve status of midwifery as a profession.

Predictors of Availing Maternal Health Schemes: A community based study in Gujarat, India

Background: India continues to face challenges in improving key maternal health indicators with about 1/3rd of global maternal deaths happening in India. Utilization of health care services is an important issue in India with significant proportion of home deliveries and majority of mothers not receiving adequate antenatal care. Mortality among poor rural women is the highest with lowest utilization. To make maternal healthcare more equitable, numerous schemes such as Janani Suraksha Yojana, Chiranjeevi Yojana, Kasturba Poshan Sahay Yojana have been introduced. Studies suggest that utilization of such schemes by target population is low and there is a need to understand factors affecting maternal health care utilization in the context of these schemes. Current community based study was done in rural Gujarat to understand characteristics of women who utilize such schemes and predictors of utilization. Methodology: Data collection was done in two districts of Gujarat from June to August, 2013 as a pilot phase of MATIND project. Community based cross-sectional study included 827 households and socio-demographic details of 1454 women of 15-49 years age groups were collected. 265 mothers, who had delivered after 1st January, 2013 are included in the regression analyses. The data analysis carried out with R version 3.0.1 software.  Results: The analysis indicates socioeconomic variables such as caste, maternal variables such as education and health system variables such as use of government facility are important predictors of maternal health scheme utilization. Results suggest that socioeconomic and health system factors are the best predictors for availing scheme. Conclusion: Health system variables along with individual level variables are important predictors for availing maternal health schemes. The study indicates the need to examine all levels of predictors for utilizing government health schemes to maximize the benefit for underserved populations such as poor rural mothers

Community level barriers for cervical cancer screening in marginalized population

Background: In India, cervical cancer is the second common cause of cancer deaths among women of reproductive age, with 469 million Indian women at risk. High risk human papillomavirus genotypes mainly 16 and 18 account of cervical cancer. The burden of cervical cancer can be reduced by regular screening of human papillomavirus (HPV). There is no specific national program for cervical cancer screening. Eligible women have limited knowledge of screening and also limited access to preventive screenings.Methods: The study was conducted in the slum areas of Ahmedabad city in Gujarat. 1088 women between 30-45 years of age were recruited in the study and 536 women consented to give cervical samples for DNA based HPV testing. We collected information regarding knowledge and practice for cervical cancer and HPV along with demographic data.Results: Lack of knowledge and practices around cervical cancer and screening among community women was found. There is a lack of awareness about the importance of preventive healthcare and near absence of evidence-based practices. Sociodemographic characteristics are important predictors of participation in the screening program.Conclusions: In the Indian context, HPV testing is a cost-effective option to prevent cervical cancer. The burden of cervical cancer is incredibly high. With increased ability to accurately detect, population level HPV testing would reduce the burden of cervical cancer and the ultimate cost per person would be minimal, due to the country’s large population. There is a need to develop policy to ensure participation of women in the HPV based cervical cancer screening programs

Maternal Health Situation in India: A Case Study

Maternal Health Services are one of the basic health services to be provided by nay government health system as pregnant women are one of the most vulnerable victims of dysfunctional health system, India, in spite of rapid economic progress is still farm away from the goal of lowering maternal mortality to less than 100 per 100,000 live births. It still accounts for 25.7% maternal deaths. The maternal mortality in India varies across the states. Geographical vastness and socio-cultural diversity make implementation of health sector reforms a difficult task. The chapter analyses the trends in maternal mortality and various maternal health programs implemented over the years including the maternal health care delivery system at various levels including the recent innovative strategies. It also identifies the reasons for limited success in maternal health and suggests measures to improve the current maternal health situation. It recommends improvement in maternal death reporting, evidence based, focused, long term strategy along with effective monitoring of implementation for improving Maternal Health situation. It also stress the need for regulation of private sector and proper Public Private Partnership (PPP) policy together with a strong political will for improving Maternal Health.

Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu

India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world’s largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women’s access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women’s use of maternal health services in Gujarat and Tamil Nadu. Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women’s education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands’ education predicted institutional delivery in Gujarat. Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.https://doi.org/10.1186/s41043-015-0025-

Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu

Background: India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world\u2019s largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women\u2019s access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women\u2019s use of maternal health services in Gujarat and Tamil Nadu. Methods: Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. Results: Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women\u2019s education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands\u2019 education predicted institutional delivery in Gujarat. Conclusions: Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood

Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program

Background: The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program. Methods: Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012\u20132013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed. Results: Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector. Conclusions: CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government\u2019s efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector\u2019s ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased