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.

Enhanced Privacy Preserving Accesscontrol in Incremental Datausing Microaggregation

In microdata releases, main task is to protect the privacy of data subjects. Microaggregation technique use to disclose the limitation at protecting the privacy of microdata. This technique is an alternative to generalization and suppression, which use to generate k-anonymous data sets. In this dataset, identity of each subject is hidden within a group of k subjects. Microaggregation perturbs the data and additional masking allows refining data utility in many ways, like increasing data granularity, to avoid discretization of numerical data, to reduce the impact of outliers. If the variability of the private data values in a group of k subjects is too small, k-anonymity does not provide protection against attribute disclosure. In this work Role based access control is assumed. The access control policies define selection predicates to roles. Then use the concept of imprecision bound for each permission to define a threshold on the amount of imprecision that can be tolerated. So the proposed approach reduces the imprecision for each selection predicate. Anonymization is carried out only for the static relational table in the existing papers. Privacy preserving access control mechanism is applied to the incremental data

Fixed Point Theoremsrelated To Compact Metric Spaces

In the present paper we established a fixed point theorem in compact metric space and another result is proved for pseudo compact tichnov space. Our results are generalization form of many known results. Keywords: Compact metric spaces, Pseudo compact tichnov spaces, fixed point AMS subject classification: 47H10, 54H2

Assessing the Regional and District Capacity for Operationalizing Emergency Obstetric Care through First Referral Units in Gujarat

Maternal mortality remains to be one of the very important public health problems in India. The maternal mortality estimates, is about (300-400/100,000 live births). There are diverse management issues, policy barriers to be overcome for improving maternal health. Especially, the operationalization of Emergency Obstetric Care (EmOC) and access to skilled care attendance during delivery. This study focuses on understanding the regional and district level capacity of the state government to operationalize First Referral Units for providing Emergency Obstetric care. This study is a part of a larger project for strengthening midwifery and Emergency Obstetric Care in India. The study apart from giving an in-depth insight into the functioning of various health facilities highlights the results from the basic to the more comprehensive level of EmOC services. It gives recommendation on various measures to rectify shortcomings noticed and make EmOC a more effective at different levels in the State of Gujarat. The study uses both primary and secondary data collection. The study was conducted in six regions of Gujarat -one district from each of these regions was selected. Out of these districts 27 health facilities were examined, which consists of seven district hospitals, eight designated as first referral units (FRU), four community health centers (CHC) and eight 24/7 primary health centers (PHC). Detailed field notes for individual facilities were prepared and analyzed subsequently for all facilities together. A common feature among all health centres were issues related to general infrastructure. Many times infrastructure planning (location, layout and maintenance) is left to engineers, who have limited knowledge about proper EmOC services. Poor infrastructure leads to poor quality of health services and wastage of resources. Through National Rural Health Mission (NRHM) and Rogi Kalyan Samiti funds major and minor repair/renovations are taking place to improve hospital buildings. In some health facilities from poor resource setting with high demand from patients were still able to deliver services. Human resources analysis suggests that there is shortage of specialists at FRUs, and committed nursing staff in labor room. As result of the Chiranjeevi initiative, the Below Poverty Line (BPL) population who earlier used to public health facilities are now accessing private facilities for delivery, and this has affected and decreased the workload of the public health facilities. Furthermore, there is lack of managerial skills at senior level hospital staff. Registers like birth, drug, Medical Termination of Pregnancy are maintained but not in standard format. Since complicated cases are not registered properly, maternal deaths are not reported. Even though the system of monitoring is well established at the state and district level, they are not properly followed. The funds for operationalization of First Referral Units come from department of family welfare. However, the administrative control is in the hands of department of medical services. Due to this factor monitoring system has become weak. The weak link between these two departments is the Regional Deputy Director who has only one administrative staff to take care of the issues in their region. The problem of monitoring the Primary Health Centres has become smooth with the appointment of new District Project Coordinators. Some facilities especially in district hospital reported that internal meetings and monitoring are happening because of the special interest of facility managers and newly appointed assistant hospitals administrators. In lower facilities this type of internal monitoring exists in a weak form. Underutilization of government facilities is a result of poor quality of services provided. In spite of reasonably developed health system, several problems of infrastructure, staffing, accountability and management capacity contribute to the poor functioning of facilities to act as an EmOC service delivery center. Some of the major bottlenecks in improving EmOC services are limited management capacity, lack of availability of blood in rural areas and poor registration of births and deaths and no monitoring of EmOC. District hospitals, FRUs, CHCs and Sub district hospitals come under the administrative control of the department of medical services. The clinical monitoring of these facilities lies with the department of health and family welfare. At the district level monitoring of these facilities are not properly done, therefore it effects directly the operationalization of the facilities. In the absence of adequate management capacity, the operationalization of EmOC is not well planned, executed or monitored, which results in delays in implementation and poor quality of care.

Using ‘Appreciative Inquiry’ in India to improve infection control practices in maternity care : a qualitative study

ACKNOWLEDGEMENTS The inputs and facilitation of field work from the Gujarat state government officials are acknowledged. We express our gratitude to the doctors, nurses and other health facility staff for actively participating in the study. Our special thanks to Dr. Pritam Pal for capacity building of the research team for appreciative inquiry and Mr. Sanjay Joshi for follow-up of the AI process. We appreciate the help of Dr. Purvi Shah in data collection and preparing transcripts for the study. The study was funded by the John D. and Catherine T. MacArthur Foundation.Peer reviewedPublisher PD

Evaluation of management of malunited supracondylar fracture of humerus by lateral closing wedge osteotomy

Background: Various osteotomies have been in use for correction of varus deformity at elbow secondary to malunited supracondylar humerus fracture in children. The objectives of the study were to determine the efficacy & outcome of lateral closing wedge osteotomy in children as a treatment of malunited supracondylar fracture of humerus with cubitus varus and to evaluate various technical problems, morbidity, complications of Lateral closing wedge osteotomy and to suggest ways to overcome them.Methods: This prospective study was conducted among 50 cases of malunited supracondylar fracture of humerus who visited in OPD during 1st September 2008 to 31st August 2010. After pre-operative assessment, lateral closing wedge osteotomy was done and fixed with two 3.5 mm screws, figure of eight tension band stainless steel wire and a supplemental lateral k-wire. Post operatively x-ray of patient was taken and carrying angle and range of movement were calculated. Patients were re-assessed at complete union.Results: Maximum patients were from the age group of 8 to 10 years- 22 cases, mean age 13.08 years, 80% male. Left (non-dominant) side was involved in 30 (60%) cases. Around 18% cases developed complications. 25 (50%) patients had no loss of range of movement and 2 (4%) had 16 to 20 degrees loss of range of movement. Almost 36 (72%) cases had excellent outcome, 11 (22%) cases had good outcome, 3 (6%) cases had poor outcome due to loss of fixation, 47 (94%) patients/parents were satisfied with the final outcome.Conclusions: Lateral closing wedge osteotomy with a lateral K-wire is a sound, cost-effective, technically less demanding modality of treatment for varus deformity due to malunited supracondylar fracture of humerus in children with minimum complications

The Role of the District Public Health Nurses: A Study from Gujarat

The role of District Public Health Nurses (DPHN) and District Public Health Nurse Officers (DPHNOs) as supervisors of the Public Health nursing and midwifery staff in a district was investigated. Thirteen DPHNs and DPHNOs from six districts selected from six geographic zones of Gujarat were observed for one week using the time motion method. Their activities and time spent were noted and the DPHNs/DPHNOs and their supervisors were interviewed. The role of the DPHNs has reduced over the years because they have not been assigned new roles with change in programmes and policies. Most of the DPHNs have training for clinical work in hospitals. Their 10 month training to qualify for PHN is inadequate to develop knowledge and skills in public health. There is a gap between their training and posting due to delays in government procedures of promotion. The DPHN/DPHNOs spend majority of their time in the office (49%) where they have a limited role. Their supervisory role for nurses and midwives has lost its importance. They spend about 1/3rd of their time in field supervision mostly visiting centres accessible by public transport as they do not have an allotted government vehicle. As they do not submit any field report, there is no follow-up action from their visit. Nevertheless they seem to have an important role in solving problems of field workers as they are mediators between the district and peripheral facilities. To conclude the DPHNs are under utilized which affects the quality of maternal and child health services in the district.

Preparing midwives as a human resource for maternal health : pre-service education and scope of practice in Gujarat, India

One key strategy to achieve reduction in maternal and neonatal mortality is to scale up the availability of skilled birth attendants (SBAs). The staff nurses (i.e., registered nurse and midwives) are skilled birth attendants recognized by the government of India. Aim and objectives: This thesis studied women‘s choices, perceptions, and practices related to childbirth, and how these were affected by modernity in general and modernity brought in by maternal health policies (Paper-I). The midwifery scope of practice of staff nurses was studied in government facilities (Paper-II). The confidence of the final-year students on selected midwifery skills, from the diploma and bachelor‘s programmes, was assessed against the list of competencies of the International Confederation of Midwives (ICM) (Paper-III). The teaching and learning approaches associated with confidence were also studied (Paper-IV). Methods: The grounded theory approach was used to develop models for describing the transition in childbirth practices amongst tribal women (Paper -I) and to describe the scope of midwifery practice of staff nurses (Paper-II). Data used for Paper-I included eight focus groups with women and five in-depth interviews with traditional birth attendants and staff nurses. For Paper-II, 28 service providers and teachers from schools of nursing were interviewed in depth. A cross sectional survey design was used to assess the confidence of final-year students from 25 randomly selected educational institutions stratified by type of programme (diploma/bachelor‘s) and ownership (private/government) (Paper-III & IV). Students assessed their confidence using a 4-point Likert scale in the competency domains of antepartum, intrapartum, postpartum, and newborn care. Explorative factor analysis using principal component analysis (PCA) was used to reduce skill statements into subscales for each domain. Crude and adjusted odds ratios with 95% CI were calculated to compare students with high confidence (≤75th percentile of scores) and those without high confidence (> 75th percentile) to compare diploma and bachelor students (Paper-III) and to study the association of teaching-learning methods and high and not high confidence for each subscale (Paper -IV). Results: A transition in childbirth practices was noted amongst women—a shift from home to hospital births seen as a trade-off between desirables (i.e., secure surroundings) and essentials (i.e., reduced risk of mortality)‘ (Paper-I). General development, increased access to western medical care, and international/national maternal health policies socialized women into western childbirth practices. The communities increasingly relied on hospitals as a consequence of role redefinition and deskilling of the Traditional Birth Attendants. Existing cultural beliefs facilitated the acceptance of medical interventions. The midwifery practice of staff nurses was ‗circumstance-driven‘ and ranged from extended to marginal because the legal right to practice was unclear Paper-II). Their restricted practice led to deskilling, and extended practice was perceived as risky. The clinical midwifery education of students was marginalized. Because of dual registration as nurse and midwife, the identity of a nurse was predominant. From 633 students, 25-40% scored above the 75th percentile and 38-50% below the 50th percentile of confidence in all subscales Paper-III). A majority had not attended the required number of births prescribed by the Indian Nursing Council. The diploma students were 2-4 times more likely to have high confidence in all subscales compared to the bachelor students. High confidence was associated with number of births attended, practice on manikins, and being satisfied with supervision during clinical practice (Paper-IV). Conclusions: Access to hospitals increases women‘s choices for childbirth in the context of high mortality. Inequitable distribution of health facilities requires region specific strategies. The women are dissatisfied with the psychosocial aspects of hospital care. India has a national regulatory body, but midwifery specific regulation is lacking. In this situation, the midwifery scope of practice of staff nurses is undefined. The pre-service midwifery education does not develop student‘s confidence to provide first level care for childbirth, as expected by the governments. Short-term and long-term measures to professionalize midwives in India are suggeste

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.