Factors governing the performance of Auxiliary Nurse Midwives in India: A study in Pune district

Factors influencing maternal death in Cambodia, Laos, Myanmar, and Vietnam countries: A systematic review

BACKGROUND

A maternal mortality ratio is a sensitive indicator when comparing the overall maternal health between countries and its very high figure indicates the failure of maternal healthcare efforts. Cambodia, Laos, Myanmar, and Vietnam-CLMV countries are the low-income countries of the South-East Asia region where their maternal mortality ratios are disproportionately high. This systematic review aimed to summarize all possible factors influencing maternal mortality in CLMV countries.

METHODS

This systematic review applied "The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist (2020)", Three key phrases: "Maternal Mortality and Health Outcome", "Maternal Healthcare Interventions" and "CLMV Countries" were used for the literature search. 75 full-text papers were systematically selected from three databases (PubMed, Google Scholar and Hinari). Two stages of data analysis were descriptive analysis of the general information of the included papers and qualitative analysis of key findings.

RESULTS

Poor family income, illiteracy, low education levels, living in poor households, and agricultural and unskilled manual job types of mothers contributed to insufficient antenatal care. Maternal factors like non-marital status and sex-associated work were highly associated with induced abortions while being rural women, ethnic minorities, poor maternal knowledge and attitudes, certain social and cultural beliefs and husbands' influences directly contributed to the limitations of maternal healthcare services. Maternal factors that made more contributions to poor maternal healthcare outcomes included lower quintiles of wealth index, maternal smoking and drinking behaviours, early and elderly age at marriage, over 35 years pregnancies, unfavourable birth history, gender-based violence experiences, multigravida and higher parity. Higher unmet needs and lower demands for maternal healthcare services occurred among women living far from healthcare facilities. Regarding the maternal healthcare workforce, the quality and number of healthcare providers, the development of healthcare infrastructures and human resource management policy appeared to be arguable. Concerning maternal healthcare service use, the provisions of mobile and outreach maternal healthcare services were inconvenient and limited.

CONCLUSION

Low utilization rates were due to several supply-side constraints. The results will advance knowledge about maternal healthcare and mortality and provide a valuable summary to policymakers for developing policies and strategies promoting high-quality maternal healthcare.

Strengthening midwifery in the South-East Asian region: A scoping review of midwifery-related research

Improving sexual, reproductive, maternal, newborn, and adolescent health outcomes necessitates greater commitment to, and investments in, midwifery. To identify future research priorities to advance and strengthen midwifery, we conducted a scoping review to synthesise and report areas of midwifery that have been explored in the previous 10 years in the 11 countries of the World Health Organization's South-East Asia region. Electronic peer-reviewed databases were searched for primary peer-reviewed research published in any language, published between January 2012 and December 2022 inclusive. A total of 7086 citations were screened against the review inclusion criteria. After screening and full text review, 195 sources were included. There were 94 quantitative (48.2%), 67 qualitative (34.4%) and 31 mixed methods (15.9%) studies. The majority were from Indonesia (n = 93, 47.7%), India (n = 41, 21.0%) and Bangladesh (n = 26, 13.3%). There were no sources identified from the Democratic People's Republic of Korea or the Maldives. We mapped the findings against six priority areas adapted from the 2021 State of the World's Midwifery Report and Regional Strategic Directions for Strengthening Midwifery in the South-East Asia region (2020-2024): practice or service delivery (n = 73, 37.4%), pre-service education (n = 60, 30.8%), in-service education or continuing professional development (n = 51, 26.2%), workforce management (n = 46, 23.6%), governance and regulation (n = 21, 10.8%) and leadership (n = 12, 6.2%). Most were published by authors with affiliations from the country where the research was conducted. The volume of published midwifery research reflects country-specific investment in developing a midwifery workforce, and the transition to midwifery-led care. There was variation between countries in how midwife was defined, education pathways, professional regulation, education accreditation, governance models and scope of practice. Further evaluation of the return on investment in midwifery education, regulation, deployment and retention to support strategic decision-making is recommended. Key elements of leadership requiring further exploration included career pathways, education and development needs and regulatory frameworks to support and embed effective midwifery leadership at all levels of health service governance.

Perceived Gaps in Academic Training and Expectations From Refresher Training in Primary Care Nurses at an Urban Metropolis in Northern India: A Qualitative Study

Background Nursing professionals, comprising the largest workforce engaged in the primary healthcare system, play a pivotal role in addressing population health needs. However, gaps in the training of nurses and midwives in lower-middle-income countries may undermine their performance and necessary skill development for fulfilling key population health needs. Substantial challenges exist in improving the regular curricular and refresher training of diplomate nurses and midwives working in primary care facilities and supporting both clinical care and health promotion functions. The study objective was to conduct a gap analysis in the present nursing curriculum and training profile of general duty midwives working in urban primary health facilities and understand their expectations and preferences from the planned refresher training course.  Methods We conducted a qualitative explorative study among General Nursing midwives (GNMs) working in urban primary health facilities in the Gurugram district of Haryana, India to conduct a gap analysis in their present curriculum and training preferences.  Results A total of 17 nurses with a mean (SD) age of 33.52 (4.75) years and an average nursing work experience of 5.35 (0.56) years were interviewed in-depth. Lack of practical applicability, complex study material, inexperienced tutors, and weak English language comprehension were key barriers in the existing nursing curriculum. The nurses expressed willingness to participate in refresher training with varied expectations, although there existed a distinct preference for short, flexible, and blended online-offline modes of training.  Conclusions Strengthening GNM nursing education should be prioritized in Indian health settings with the focus on improving student comprehension through vernacular instruction when feasible, and capacity building of tutors, with avenues for continued training and education. There is also a need for strengthening the curriculum related to key emergent public health challenges related to non-communicable diseases and mental health, as also skills for client and patient counseling and communication.

How WhatsApp is transforming health communication among frontline health workers: a mixed-method study among midwives in India

BACKGROUND

Limited literature exists in India on WhatsApp use for health communication among frontline health workers like Auxiliary Nurse Midwives (ANM). We conducted this study to assess the adoption of WhatsApp among ANMs and identify factors influencing its adoption. In addition, the study explored the perceptions of ANMs on WhatsApp use for sharing health information.

METHODS

We employed a mixed-method sequential explanatory design. We surveyed 259 ANMs, followed by in-depth interviews with 19 purposively sampled ANMs. We conducted multinomial logistic regression to identify factors associated with WhatsApp adoption and employed thematic analysis to analyze interviews.

RESULTS

257 ANMs responded to the survey questionnaire, of which 18.3%, 48.2%, and 33.5% had low, mid, and high levels of WhatsApp adoption, respectively. Education (AOR = 2.87 [95% CI = 1.20-6.85]), motivation (AOR = 6.31 [95% CI = 1.43-27.80]), and technical awareness (AOR = 2.91 [95% CI = 1.11-7.62]) were significantly associated with WhatsApp adoption. Thematic analysis of the interviews resulted in six themes describing perceptions and experiences of ANMs on WhatsApp use. They are: (i) a way of instant communication, (ii) provision for multimedia messaging, (iii) a quick fix tool for queries and concerns, (iv) make attendance and reporting easy (v) a way of reaching higher officials, and (vi) a cost-saving mechanism.

CONCLUSION

WhatsApp facilitated ANMs' communication and service delivery at the grassroots level. Measures to improve motivation, technical awareness, and digital education will likely improve WhatsApp adoption among health workers.

Perceptions of healthcare providers and mothers on management and care of severely wasted children: a qualitative study in Karnataka, India

OBJECTIVES

To explore perceptions of healthcare providers and mothers of children with severe wasting on the perceived reasons for severe wasting, constraints on the management and barriers to caregiving and care-seeking practices.

DESIGN

In-depth qualitative interviews conducted with healthcare providers and mothers of children with severe wasting.

SETTING

Urban and rural locations in Karnataka state, India.

PARTICIPANTS

Healthcare providers (anganwadi workers, accredited social health activists, auxiliary nurse midwives, junior health assistant, medical officers, nutrition counsellors) from public healthcare centres and mothers of children with severe wasting.

RESULTS

Forty-seven participants (27 healthcare providers, 20 mothers) were interviewed. Poverty of households emerged as the underlying systemic factor across all themes that interfered with sustained uptake of any intervention to address severe wasting. Confusion of 'thinness' and shortness of stature as hereditary factors appeared to normalise the condition of wasting. Management of this severe condition emerged as an interdependent phenomenon starting at the home level coupled with sociocultural factors to community intervention services with its supplemental nutrition programme and clinical monitoring with therapeutic interventions through an institutional stay at specialist referral centres. A single-pronged malnutrition alleviation strategy fails due to the complexity of the ground-level problems, as made apparent through respondents' lived experiences. Social stigma, trust issues between caregivers and care-seekers and varying needs and priorities as well as overburdened frontline workers create challenges in communication and effectiveness of services resulting in perpetuation of severe wasting.

CONCLUSIONS

To ensure a continuum of care in children with severe wasting, economic and household constraints, coordinated policies across the multidimensional determinants of severe wasting need to be addressed. Context-specific interventions are necessary to bridge communication gaps between healthcare providers and caregivers.

"We are nurses - what can we say?": power asymmetries and Auxiliary Nurse Midwives in an Indian state

In India, nurses and midwives are key to the provision of public sexual and reproductive health services. Research on impediments to their performance has primarily focused on their individual capability and systemic resource constraints. Despite emerging evidence on gender-based discrimination and low professional acceptance faced by these cadres, little has been done to link these constraints to power asymmetries within the health system. We analysed data from an ethnography conducted in two primary healthcare facilities in an eastern state in India, using Veneklasen and Miller's expressions of power framework, to explore how power and gender asymmetries constrain performance and quality of care provided by Auxiliary Nurse Midwives (ANMs). We find that ANMs' low position within the official hierarchy allows managers and doctors to exercise "power over" them, severely curtailing their expression of all other forms of power. Disempowerment of ANMs occurs at multiple levels in interlinked and interdependent ways. Our findings contribute to the empirical evidence, advancing the understanding of gender as a structurally embedded dimension of power. We illustrate how the weak positioning of ANMs reflects their lack of representation in policymaking positions, a virtual absence of gender-sensitive policies, and ultimately organisational power structures embedded in patriarchy. By deepening the understanding of empowerment, the paper suggests implementable pathways to empower ANMs for improved performance. This requires addressing entrenched gender inequities through structural and organisational changes that realign power relations, facilitate more collaborative ways of exercising power, and create the antecedents to individual empowerment.

Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India

BACKGROUND

Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality.

METHODOLOGY

The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0-59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs).

FINDINGS

A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0-6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7-59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI.

CONCLUSION

The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7-59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7-59 days old fast breathers and recommend a review of the current national policy.