Evidence based advocacy for maternal and neonatal health (2007-2014)
ARTH undertook evidence-based advocacy for maternal-neonatal health (including safe abortion) across the seven divisions of Rajasthan state, using a gender, rights and health systems approach, in collaboration with the Department of Medical Health and Family Welfare Services, Government of Rajasthan. The focus of ARTH’s advocacy efforts emerged from the various research studies that it had conducted. One of these was a qualitative study on neonatal care and childbirth practices at home and institutions, another was a quantitative survey of delivery practices, and there were 2 verbal autopsy studies for maternal deaths. These studies had thrown light on very crucial issues, including quality of delivery services, referral mechanisms, timing of discharge, costs of services and immediate neonatal and maternal care at home and in institutions. As a part of this advocacy, various activities were carried out:
SAMPARK – To improve the referral system and emergency obstetric care services (2015-2018)
Places of operation/activity: District Population covered Bharatpur 25,48,462 Chittorgarh 15,44,338 Sawai Madhopur 13,35,551 Introduction: Maternal death is defined as “The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. The top causes of maternal deaths are: postpartum bleeding, complications from unsafe abortion, hypertensive disorders of pregnancy, postpartum infections and obstructed labour. Most maternal deaths are avoidable, as the healthcare solutions to prevent or manage complications are well known. Improving access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth will reduce maternal deaths significantly. Situation Analysis: Rajasthan is a state with a population of 6,85,48,437, 75% of which is rural (Census 2011), and had a high maternal mortality ratio of 255 per lakh live births (SRS 2010-12). Even though the health facilities had increased in number there was no consequent decrease in Maternal Mortality Ratio. The government system provides the bulk of maternal health services. Although the service infrastructure had improved in stages, the availability of maternal health services in rural areas remains poor because of low availability of human resources, especially midwives and clinical specialists, and their non-residence in rural areas. Various national programmes, such as the Family Planning, Child Survival and Safe Motherhood and Reproductive and Child Health, had attempted to improve maternal health; however, they had not made the desired impact either because of an earlier emphasis on ineffective strategies, slow implementation as reflected in the poor use of available resources, or lack of effective ground-level governance, as exemplified by the widespread practice of informally charging users for free services. The availability of safe abortion services is limited, resulting in a large number of informal abortion service providers and unsafe abortions, especially in rural areas. The Janani Suraksha Yojana provides an opportunity to improve maternal and neonatal health, provided the quality issues can be adequately addressed. After the implementation of Jannani Suraksha Yojna there was a 3 fold rise in institutional deliveries but MMR had not declined appreciably. The possible reason could be the poor referral system in the state. According to a review of maternal deaths in Rajasthan in 2012, 22% of maternal deaths occurred in vehicles while 65% in hospitals. Interventions At the community level: Orientation of ASHAs was carried out by 4 ARTH representatives in Chittorgarh = 11, Bharatpur = 10 and Sawai Madhopur = 8. IEC materials were distributed among the ASHAs to impart knowledge in the community regarding complications during pregnancy and some case studies from a previous project called PARIJAAT were also distributed to assess the knowledge of the ASHAs regarding maternal complications. By the end of 31st March 2016 following are the key achievements under the project: A total of 2,617 patients were helped through the intervention,out of which 705 were directly helped and 1,912 were helped through the four operating call centers. Of the total of 2617 patients benefited through the Sampark Intervention, 2,014 (78%) were discharged after referral care whereas a 193 (7.4%) cases were further referred to the higher healthcare facilities. There was a healthy number of patients, who were alive after the emergency maternal obstetric care, at 2,103 amounting to 80.4%. The combined number of deaths at the time of exit for all the four intervention areas was 55 whereas the outcome after 28/42 days of completion of the intervention, the combined death figure was 108.
Strengthening Pre-service Nursing and Midwifery Education in Udaipur Division of Rajasthan (2011-2014)
ARTH in partnership with UNFPA and Department of Medical, Health and Family Welfare, Government of Rajasthan worked to strengthen pre-service education for nursing and midwifery cadres in 5 districts of Udaipur zone in the state of Rajasthan. The project covers 5 ANM and 2 GNM training centres at Banswara, Dungarpur, Chittorgarh, Rajsamand and Udaipur and aimed to improve the educational and clinical skills of nursing faculties of ANM/GNM training centres and strengthen attached clinical practice site by upgrading the clinical training capacity of the service providers. ARTH named the initiative as “Kushal project”, meaning a project to improve training and clinical skills. A Quality Improvement (QI) team conducted the baseline survey covering 5 broad areas viz. This was done according to allotted standards and gaps were identified within the training facilities. After identification of gaps, separate action plans were developed at the three levels viz. school, district and state level. Results: The project findings indicated marked improvement in the teaching methodology with improved infrastructure in terms of skill-labs, computer labs and library facilities. Additionally clinical practices in service sites showed considerable improvement followed by better maintenance of records both at the teaching and non-teaching levels.
School of Midwifery Practice & Training in Primary Health Care (2007 onwards)
ARTH has been working as a technical resource agency since 1997. It has periodically conducted training courses for government ANMs, doctors, and programme managers of NGOs. Since 2007, ARTH has consolidated its role of providing technical assistance and training by establishing the School of Midwifery Practice & Training in Primary Health Care. The broad objective of the school is to equip primary health service providers, managers and organizers from the non-profit and government sectors, including ARTH’s field team to improve the delivery and utilisation of primary health services in rural Rajasthan. ARTH has expanded its training infrastructure and faculty. A training centre has been constructed 20 kms from Udaipur city. In order to facilitate training of various levels of personnel, ARTH has developed a variety of training materials, such as a facilitator guide for trainers of nurse-midwives on maternal – newborn care and several pictorial materials for village level health workers/ASHAs. Training programmes have been held for various cadres of people working on reproductive and child health issues – senior NGO managers, doctors, programme supervisors, nurse midwives, village health workers and their trainers etc. Since its inception in 2007, the school has trained 217 SBA trainers from various parts of Rajasthan (these include nursing tutors from ANM and GNM training centers, staff nurses from teaching hospitals, labour room in-charge from district hospitals/ CHCs/ referral hospitals). In 2009-10 we conducted a training of nurses (on issues of contraception, RTI/STI, breast & pelvic examination, safe abortion, infection prevention, IMNCI) from 3 NGOs of Rajasthan that are running rural health centres. We conducted 2 training programmes on reproductive rights and safe abortion in which 59 field level supervisors from 31 NGOs participated. We also conducted an orientation-training course on primary health for the field supervisors of 2 NGOs, one of whom ARTH provided technical support to implement health interventions in its field area. Young men and women living in the rural-tribal interiors rarely get to enter medical and nursing schools, hence health care in these areas is delivered largely by “outsiders” that are reluctant to live and work in a marginalised area. Yet the health needs of these areas tend to be greater than average. Recognising this, in 2016, ARTH launched training of “Skilled Health Assistants” with a first batch of 9 locally resident school educated women enrolling for an intensive 3 month course to become Midwifery Assistants and counsellors. The course curriculum was meticulously designed and delivered by the experienced nurse-midwives and doctors making use of experiential learning methods, training aids and practical demonstrations through dummies and bedside training. After a rigorous examination, 8 students were declared successful and assigned to the two rural health centers by rotation. As of September 2024, we have successfully trained ___ SHAs, some of whom work in ARTH’s three health centres and others have moved on to other professions.
Strengthening government efforts to implement the MTP Act in districts of Rajasthan (2007 onwards)
ARTH is one of the eight members of the Consortium for Safe Abortion in India, which works towards increasing access to legal, safe and comprehensive abortion care services in the public health system, focusing on the rural poor. In October 2006, ARTH worked with the Medical, Health and Family Welfare Department, Rajasthan to “assist it on systemic, resource, administrative and legal issues to increase access to safe and legal abortions in the public and private sectors”. Data was collected from all the districts of the State to review the status of implementation of the MTP Act in the districts. Data on MTP certification process, MTP reporting, currently available MTP trained providers, functioning of the district level MTP committee and status of PCPNDT implementation was collected. The collected data was used to plan measures along with the State government to improve access to safe abortion services within the provisions of the MTP Act. Data from April 2007 to March 2010 was collected, compared and documented, and shared with the Department of Medical Health & Family Welfare, Government of Rajasthan. An MIS for reporting about MTPs at district level and from district to state headquarters was developed. Besides supporting and advocating with the government sector, we did a series of workshops with NGOs. Till March 2010, 3 residential trainings and 5 one-day trainings with local NGOs were conducted. We prepared a series of posters, brochures and a documentary film on the issue of safe abortion and sex selection to strengthen the advocacy campaign.
Establishing a system for reviewing maternal deaths, using verbal autopsy technique in Udaipur district of Rajasthan (2007-08)
The District RCH Society of Udaipur in collaboration with ARTH undertook a study to establish a system for identification and review of maternal deaths. The Medical, Health and Family Welfare Department, Udaipur conducted verbal autopsies of maternal deaths in two blocks of the district. At the same time ARTH conducted verbal autopsies in two other blocks of the district using a “gold standard” method that picks up all maternal deaths in the study area during a given time period. The study was carried out from December 2006 to November 2007. The MAPEDI questionnaire (UNICEF’s questionnaire for Maternal Perinatal Death Inquiry) was used to conduct the verbal autopsies. These two study approaches were adopted in roughly equal populations across the four blocks — in the blocks covered by the health department, which relied on the civil registration system, 9 deaths were picked up, while 57 deaths were picked up in the blocks covered by ARTH, which relied on a range of key informants, e.g. ASHAs, ANMs, Anganwadi workers. In the data collected by ARTH, 36% women died at home, 41% died in a health facility, while 19% died during transport. 16% women died during pregnancy, 18% due to abortion related causes and maximum 66% died in the post-partum period. Among key informants, maximum maternal deaths were reported by village level female workers – ASHA, Anganwadi worker, Anganwadi sahayika.
Supporting NGOs for providing maternal-newborn related health services (2003-2010)
ARTH provided support to 2 NGOs of Rajasthan – SRKPS in Jhunjhunu and Shiv Shiksha Samiti in Tonk to provide 24*7 maternal and child health services centred on nurse midwives. Each health center was providing services to a total population of approximately 20,000. ARTH provided the following support: Between April 2008 and March 2010, these centres have seen 14411 patients in OPD and 5573 patients in field clinics. Of these client visits, 62 % were women’s care. Additionally these health centres have managed 612 deliveries. The experience with these NGOs demonstrates that it is feasible to provide a package of services through nurse-midwife operated health centres, especially 24*7 delivery services. Models like these prove that NGOs not headed by medical persons can also manage health services, however they need adequate technical and programmatic support in initial years. In such models, economies of scale can be realised, by applying the norms of a revenue model. These models are an alternative to gynaecologist and doctor driven MNH service models. They demonstrate value-added roles for midwives (ANMs & GNMs) and contribute to the discourse on skilled attendance.
Technical assistance on RCH initiatives to 8 NGOs of northern Rajasthan (2001-02)
ARTH provided technical assistance to enhance the capacity of a network of eight field based NGOs implementing community based reproductive and child health programmes in rural areas of northern Rajasthan. Series of field visits and orientation meetings were organised to assess the NGOs’ organisational needs and to foster consensus among them on maternal health programme approaches. ARTH helped them in implementation and maintaining MIS. Key activities undertaken:
Centre For Contraception Research (CCR)
Established in 2020 as a research unit of ARTH society, Centre for Contraception Research works for advancing contraception policy and practice in India through implementation-research, dissemination and advocacy. It works as an independent unit within the organization and draws on professional resources and skills as needed, to focus on implementation issues that are relevant to policy and programmes in large north Indian states like Rajasthan. The Centre has started with following objectives: A five member Research Advisory Committee (RAC) guides CCR in establishing a set of priorities along with dissemination and linkage to advocacy groups and activities. To carry credibility independent of the CCR, the RAC does not involve itself in implementation of activities. The centre has started exploring following research priorities. On the basis of need and capacity, we will explore more areas. 1. Repositioning Emergency Contraception (EC) With low levels of acceptance and use, the “emergency” label on sexual activity might aggravate stigmatisation of sexual activity and in effect discourage its use. Alternate positioning of EC as a short term option for non-users might therefore be considered. Keeping this in mind, we plan to conduct formative research and test pilot interventions on repositioning emergency contraception. To start with, we conducted pilot testing with some existing users in our area which helped us to develop the research questions and study tools accordingly. 2. Contraception among migrant and long-distance couples With a large proportion of males migrating to other cities for employment, wives of migrant husbands are left behind. There is a need for spousal communication about expectations of contraception use in situations in which husband’s visits are unplanned or might be sudden. This is quite different from the need among migrant men to use condoms to prevent STI/HIV. Keeping this in mind, conducted formative research exploring determinants of contraceptive use among young migrant couples. To understand the pattern of contraception use, we conducted test interviews in our field area, which helped us to have clearer understanding of research objectives and create study tools for the same. 3. Contraception among newly weds Family expectations to demonstrate fertility, poor spousal communication, and lack of prior knowledge and access to commodities combine to make contraception an absent part of newly wed sexual activity. To understand decision making around contraception use, we are planning to conduct formative research on determinants of contraceptive decision making and use among newly wed couples in rural-tribal settings. 4. Dissemination of Work Along with this, we planned to disseminate ARTH’s work, including enabling contraception through community health entrepreneurs, the role of pregnancy self testing in promoting women’s agency in the field of SRH, and role of the Levonorgestrel intrauterine device as a long acting reversible contraceptive option.
SAFUL Project (2012-2016)
In 2012, it was estimated that 70,000-100,000 women die every year due to consequences of unsafe abortion. A majority of these deaths occur in low-income countries where induced abortion is illegal or clandestine. Unplanned pregnancy and unsafe abortion thus place a huge burden on scarce medical resources. Any improvement in comprehensive abortion care such as increased availability and acceptability of abortion services would mean important improvements for the concerned women and their families as well as for the societies at large. Thus, ARTH commenced a research trial in Udaipur and nearby district Rajsamand with the objective to assess the effectiveness and safety of self-assessment following a medical abortion procedure as compared to routine follow up. We aimed to describe the acceptability and accuracy of home assessments of abortion outcomes among women in both rural and urban settings in Rajasthan, India and to describe contraceptive use and compliance among women prior to and post a medical abortion. The research was carried out at four of ARTH’s rural health centres and one private hospital. As part of the project two-prong strategy was adopted: Under the first strategic move, two training programs were organized in which 62 providers (32 doctors & 30 senior nurse-midwives) took part from ten districts of Rajasthan. They were trained on recent updates on abortion including the legal issues, techniques and simplified procedures. Under the second strategic move, a research trial was conducted and it led to the following findings: Further qualitative interviews with the women participating in the trial on simplified medical abortion revealed the following conclusions: