Where there is no nurse: an observational study of large-scale mentoring of auxiliary nurses to improve quality of care during childbirth at primary health centres in India

Abstract

ObjectiveClinician scarcity in Low and Middle-Income Countries (LMIC) often results in de facto task shifting; this raises concerns about the quality of care. This study examines if a long-term mentoring programme improved the ability of auxiliary nurse-midwives (ANMs), who function as paramedical community health workers, to provide quality care during childbirth, and how they compared with staff nurses.DesignQuasi-experimental post-test with matched comparison group.SettingPrimary health centres (PHC) in the state of Bihar, India; a total of 239 PHCs surveyed and matched analysis based on 190 (134 intervention and 56 comparison) facilities.ParticipantsAnalysis based on 335 ANMs (237 mentored and 98 comparison) and 42 staff nurses (28 mentored and 14 comparison).InterventionMentoring for a duration of 6–9 months focused on nurses at PHCs to improve the quality of basic emergency obstetric and newborn care.Primary outcome measuresNurse ability to provide correct actions in managing cases of normal delivery, postpartum haemorrhage and neonatal resuscitation assessed using a combination of clinical vignettes and Objective Structured Clinical Examinations.ResultsMentoring increased correct actions taken by ANMs to manage normal deliveries by 17.5 (95% CI 14.8 to 20.2), postpartum haemorrhage by 25.9 (95% CI 22.4 to 29.4) and neonatal resuscitation 28.4 (95% CI 23.2 to 33.7) percentage points. There was no significant difference between the average ability of mentored ANMs and staff nurses. However, they provided only half the required correct actions. There was substantial variation in ability; 41% of nurses for normal delivery, 60% for postpartum haemorrhage and 45% for neonatal resuscitation provided less than half the correct actions. Ability declined with time after mentoring was completed.DiscussionMentoring improved the ability of ANMs to levels comparable with trained nurses. However, only some mentored nurses have the ability to conduct quality deliveries. Continuing education programmes are critical to sustain quality gains.

Does engagement with frontline health workers improve maternal and child healthcare utilisation and outcomes in India?

“…Thus, our study supports the argument of Close To Community (CTC) potential of FHWs for expanding the utilisation of MCH services especially among the poor women, which often stand at the fringes of the health system [7,53,55]. Our findings are in keeping with previous studies that examined the role of FHWs in improving MCH care [21,22,24,27,41], and microlevel investigations in India [13,14,18,30,31,41,45].…”

“…However, enhancing engagement with FHWs can be just as cost-effective, results-driven and are shown to be a proven intervention for bringing equity in MCH care and outcomes [28,56]. However, previous studies have reported that factors such as a lack of skills, low qualifications, the multitasking nature of their job, low incentives, and low recognition is discouraging many FHWs from remaining in this profession [40,42,44,45].…”

“…Secondly, considering the federal structure of India's health care system and the diverse range of health policies and programmes across different states [45], it is important to identify the role of FHWs in enhancing MCH care and outcomes. In this direction, we use a comprehensive definition of FHWs encompassing various nomenclatures, work profiles, or functions used at the operational level in the government flagships programmes in different states.…”

In-service nurse mentoring in 2020, the year of the nurse and the midwife: learning from Bihar, India

“…Rigorous program evaluations were conducted to assess the impact of AMANAT. In a pre-post test comparison, proportional (percentage point) post interventional increases in correct actions taken by ANMs were 17.5 (95% CI 14.8 to 20.2) for managing normal deliveries, 25.9 (95% CI 22.4 to 29.4) for postpartum hemorrhage, and 28.4 (95% CI 23.2 to 33.7) for neonatal resuscitation [ 6 ]. Another similar evaluation revealed that the impact was mostly sustained, with correct intrapartum practices during normal delivery slightly changing from 44.2% (95% CI: 42.1 to 46.4) when mentoring in the last three months to 39.1% (37.7–40.5) one year post-mentoring [ 20 ].…”

“…The purpose of this ‘capacity-building’ article is to share our collective (and ongoing) experience in implementing and evaluating the world’s largest program. This is particularly important as large-scale programs present different kinds of challenges to public health practitioners and program managers [ 6 ]. In so doing, we point to a number of areas for further research and suggest implications for others designing comparable programs.…”