ROLE OF MIDWIVES IN PROMOTING RURAL HEALTH:
A case study and lessons from South India

ABSTRACT

"What a mother is to a child, an Auxiliary Nurse Midwife (ANM) is to her community. The ANM nurtures her community. Just as a mother never sleeps, an ANM never sleeps, making herself available at deliveries at all times during the night. An ANM attends to a temporary stomachache and attends to a complicated high-risk pregnancy. Sometimes, just as a child does not listen to their mother at times, the community does not listen, but the ANM continues to do her duty. The ANM is the mother of all children in the village from providing immunization to the 1 year old, to providing counseling to the 15 year old on sexual health, to delivering the child of the 22 year old to advising the mother on breastfeeding of the 24 year old to comforting the 30 year old at the tubectomy camp to assisting the 50 year old grandmother to get a cataract operation. The ANM is present in all stages of life. The ANM serves the community, reports to her PHC, all the while looking after the needs of her husband and her own children."

INTRODUCTION

India's Reproductive and Child Health (RCH) Program covers the following areas: antenatal care, postnatal care, immunization, childhood illnesses, adolescent health, family planning, domestic violence, fertility and HIV/AIDS which would come under STIs/RTIs. The program is well practised in all the areas except domestic violence and HIV/AIDS. Domestic Violence is usually the last issue to be targeted and that is only when the other areas have been under control. HIV/AIDS is gaining more attention in areas where there needs to be more focus on those issues. The Primary Health Center (PHC) through its Auxiliary Nurse Midwives (ANMs) and Multipurpose Workers (MPWs) at the sub center level carry out the RCH program. They deliver these preventive and promotive health services and health education.

APPROACHES

According to the Indian Government, there are at present 408 ANM (Female Health Workers) Training Schools with an admission capacity of 16,000. Out of the 159,777 sanctioned posts of ANMs, there are 134,112 ANMs only. The ANMs are women who attend an 18-month course after passing the 10th standard. The government, specifically the Family Welfare Program, sponsors this course and the Indian Nursing Council recognizes the course. The training is heavily focused on deliveries and there is fieldwork involved. After graduation from the course, the ANMs are placed in villages, usually in a subcenter, which acts as their residence and also as a 'maternity ward'.

The ANM's day usually begins with fieldwork. This would include conducting home visits to women who recently delivered babies, or are currently pregnant,
as well as sterilization operations. During her time in the field, men, women, and children approach her for medicine to deal with ailments such as stomachaches, diarrhea, and headaches. After her morning fieldwork, she goes back to her quarters and does the documentation on her work. At the end of the month, the ANMs spend time filling out the infamous Form # 7. Along with the ANM, there is the health worker (male) that she coordinates with to follow up on tuberculosis, malaria and other communicable diseases. She also spends her time attending monthly meetings at the PHC or at the district hospital.

CASE STUDY

In BR Hills, there are five ANMs placed within five subcenters who report to one PHC. BR Hills is located in the southern part of Karnataka State, India. These five tribal ANMs are specially trained to work in tribal areas. It is a wildlife sanctuary and home to the Soliga Tribe. The Soliga Tribe, numbering around 20,000 in the surrounding areas is a tribe that has always lived in the forest and depend on it for their livelihoods. The NGO, Karuna Trust, created in 1987 operates the PHC. This is an unique PHC because it was the first PHC in Karnataka to be operated by an NGO. The sub-centers cater for a population anywhere from two thousand to six thousand.

The ANMs' main responsibilities focus on following the prenatal cases by administering tetanus injections and iron supplements to them. They also follow through with the deliveries and provide post-natal care. Iron-Folic acid tablets (IFA), prophylactic and therapeutic doses are provided to all pregnant women. The lady Medical Officer, with assistance from the staff Nurse, handles complicated cases like breech delivery at the PHC. This primary health center focuses on early ANC registrations, immunization coverage of pregnant women, three ANC checkups, institutional deliveries and having deliveries conducted by trained birth attendants. The PHC's Annual Report also emphasizes the fact that a trained birth attendant performed 100 percent of the deliveries; there was 100 percent immunization coverage of the children.

In addition, laproscopic sterilizations are performed regularly at the tribal hospital for the eligible couples, not only for the PHC population but also to the neighboring PHCs. Sanitary Napkins are being distributed by the ANMs, anganwadi teachers and at the PHC.

The ANMs also counsel women on birth control options. This translated to, after a woman had two children, advising the woman to get a sterilization operation, (especially if the woman already had a boy child), or they are counseled on IUDS, condoms and pills, the most commonly used forms of contraception. They also attend to women during their sterilization operations. Once a month they conducted immunizations of all the children in the village. They were the source of primary care in their village attending to minor accidents with children and adults. In this PHC area, all of these services are at no cost to the people. They also maintain more than ten registers and conducted the community survey every year. The Medical Officer or the Lady Health Visitor who usually served as an ANM herself for many years supervised them.

Also, in the BR Hills area which is a tribal area, the government had put in place the Tribal ANM program where tribal girls who had at least a seventh grade education were trained to be ANMS and then placed in tribal hamlets in remote forest areas with a population of 500 each. There were sixteen tribal ANMs who reported to different PHCs. They were trained especially to serve the tribal population such as focusing on how to deliver babies in the squatting position, the traditional way of delivering babies.

LESSONS

When informally asked how their working conditions could be improved, the ANMs cited the following concerns. They mentioned that sometimes the language barrier problem is experienced during communication with the tribal population. They also undergo lack of confidence when carrying out their duties on their own. They requested for a vehicle that would take them to the interior of the forests. They had a shared need for more training on report writing and documentation. The most employed skills were the skills acquired when delivering babies, immunizing children and counseling.

As a result of these issues, a training program was developed that focused on confidence building, understanding indicators, understanding the different forms, incorporating community based rehabilitation in their work and other identified areas. When an exercise on the conditions necessary for an ideal delivery was conducted, the ANMs had a difficult time listing them. One ANM did not have a delivery table in her sub center and therefore she was conducting deliveries on the floor. Another ANM did not have a toilet in her own sub center. She was accustomed to this because the only time she ever had a toilet was when she attended the tribal residential school. Out of the five ANMs, two were not married. One of them lived with her parents and a brother in the sub center and the other had her sister's children living with them. One ANM's husband worked out of the state and he therefore traveled a few hours each day to her placement area. When asked if the high population was overwhelming, they replied they were giving their specific focus on the women of childbearing age only. It was amazing to observe that the ANMs remembered the immunized children and doses they received when many women had "misplaced" their immunization cards.

In addition to their duties, these ANMs also collected data for any small-scale studies that were conducted, such as on neonatal mortality and abortion.

CONCLUSION

Although the ANM is the change agent, the change occurs at the rate of one person at a time and one village at a time, too. An ANM has the potential to decrease maternal mortality and decrease infant morbidity and mortality, but this potential needs to be encouraged by the NGO and the community.

Other cases studied have shown that ANMs are under-skilled, under respected, and disempowered.

RECOMMENDATIONS

1. ANMs' sub centers need to be well equipped in order to provide the services that are expected of them.

2. ANMs should be encouraged to provide need-based services. They should prioritize the specific needs of the community they serve. For example, if one is serving a tribal area that does not approve the use of western medicine, one should work with the PHC to promote herbal medicine. Another example is if there are teenage pregnancy cases in the area that ANMs serve, they should also address the issue of teenage pregnancy even if they do not have adolescent sexual health programs in place.

Notes: The author spent six months at BR Hills, Karnataka as an America India Foundation Service Corps Fellow working with the RCH program. These are her observations and commentary.

Deepa Bhat
MSc -Nutrition/MPH graduate, Tufts University, Friedman School of Nutrition Science and Policy, Boston, MA, USA. Email: deepab@alumni.tufts.edu