Midwifery Initiative in Telangana State : Vanam Jwala Narasimha Rao

 Midwifery Initiative in Telangana State

Vanam Jwala Narasimha Rao

The Pioneer (06-06-2021)

The Telangana State under the leadership of CM KCR has taken many measures to provide quality maternal health services, increasing institutional deliveries and reducing maternal deaths. These measures among others include: Introduction of KCR kits and direct beneficiary transaction of Rs.12000/- to a male child and Rs.13000/- to a female child and e-governance through KCR kit web portal; Standardization of 305 labour rooms; Quality improvement by enhancing skills and practices through trainings such as Dakshata trainings, Midwifery trainings; Improving access to advanced and high quality obstetric and intensive care by establishing 22 MCH wings to provide referral transport-102 (Ammavodi) ambulances etc.  

Resultantly, the State has achieved 19-point increase in government institutional deliveries reaching 97% in institutional deliveries and 50% deliveries in the public sector and 17.1 percent decrease in maternal mortality ratio from 76 in 2014-16 to 63 per one lakh live births in 2016-18 achieving the sustainable development goal (SDG) of MMR.

Despite all these efforts, there are yet certain challenges encompassing the State that need to be addressed immediately such as: Highest C-section rate of 61% in the Country; Lack of specialists in rural/tribal areas is also a challenge for providing quality maternal care; Women experiencing any abuse like physically hit, verbal abuse, either during pregnancy or post delivery and 90% of the facilities did not allow birth companion and do not promote choice of alternate birthing positions.

The World Health Organization (WHO) estimates that 70-80% of births could be normal, natural deliveries and that the nurses trained as midwives, can provide 87% of essential care for women and newborns and there will be significantly higher rates of spontaneous vaginal delivery with respectful maternity care.

To address these challenges, Telangana State has started ‘Nurse Practitioner Midwifery (NPM) diploma course’ with duration of 18 months (one year onsite + theory sessions with 6 months internship). Per se, Telangana was the first State to implement this ‘Nurse Practitioner Midwifery (NPM) diploma course’ which was later rolled out in other States of the Country according to Commissioner Health and Family Welfare Vakati Karuna.

The selection criteria of trainees under this model included: staff nurses either in-service or from open market with minimum educational requirement of GNM or BSc Nursing degree; having more than 2 years of labour room experience and passionate about midwifery services. These nurse practitioner midwives are trained to achieve the technical competencies as per the international confederation of midwifery (ICM).

Under the National Health Mission (NHM) approved budget, the State has already trained 30 members in nurse practitioner midwifery course with technical support from UNICEF and training support from Fernandez Foundation. In addition, two batches with 189 staff nurses being trained in nurse practitioner midwifery course this year. And one batch (12 members) are being trained as Midwifery Educators.

The first batch of 30 trained midwives are currently posted in 11 TVVP (Telangana Vaidya Vidhana Parishad) facilities with high C-section rate covering 9/33 districts (27%) with 5 tribal/aspirational areas effectively covered from September 2020. These 30 trained midwives are showing promising results.

The tangible outcomes include among others: improving natural birthing with positive birthing experience; triaging high risk cases; facilitating appropriate and timely interventions by the Specialists; introducing counselling and birthing exercises; partner involvement and family support gained; increasing autonomy of choosing birthing positions; availability of skilled professionals in remote/rural areas etc.   

The intangible benefits included respectful maternal care, confidence of pregnant women and their families on midwifery led care and improved women centred care. These 30 midwives have been contributing to improvement in normal deliveries in the facilities they are deputed.

On an average, each midwife conducts around 18 deliveries per month along with conducting midwife led antenatal OPD services including counseling, risk categorization with triaging and trimester-wise birthing exercises. Further, it can be noticed that the c-section rate in these facilities dropped down from 62% in April 2020 to 52% in April 2021.

Alternate birthing positions (left lateral, propped-up, squatting, all fours, upright, standing etc) are being practiced in these facilities keeping aside the conventional lithotomy (<1%) position. The most preferred choice of the pregnant women for delivery is squatting (48%) followed by propped-up (35%) and left lateral (14%) positions.

According to Karuna Vakati, a visible change is observed wherein the pregnant women are taken care with respect allowing birth companions, counseling is done, birthing exercises are being practiced and pregnant women are encouraged in making their own choice of birthing positions. The staff nurses from the surrounding hospitals are being trained in 6 weeks short-term training for conducting natural birthing with respectful maternity care and so far, 368 staff nurses have been trained.

An independent third-party evaluation conducted on Nurse Practitioner Midwifery training and performance of midwives proved that the skills in providing ante-natal, intra-natal and postnatal care improved among the trainees says Karuna. The other outcomes included: Improved continuum of care throughout the labour; allowing ambulation and intake of food/ water; 90% of deliveries without induction; routine episiotomy avoided in 85% of the cases; no perineal tear in 48% of the cases and only 3% of cases required transitioning to specialized obstetric care.

The following roadmap is laid for moving forward with the midwifery initiative: Training of 1512 staff nurses in nurse practitioner midwifery (NPM) by the year 2026 so that having 40-45 midwives posted in areas where skilled care is scarce in all 33 districts; strengthening the Government Nursing Colleges as State Midwifery Training Institutes (SMTIs); setting up of midwifery led care units (MLCUs) at the training sites and 10 facilities with first batch NPMs; involving State Nursing Council and Government Nursing Colleges in registration, training and conducting examinations of enrolled students for NPM and midwifery educators training; training of gynecologists in alternate birthing positions and respectful maternity care; improving quality of maternal care through counseling, birthing exercises, allowing birth companions and providing autonomy to the pregnant women in making a choice of birthing positions and conducting weeks short-term training for staff nurses to enhance their skills in conducting normal deliveries and practicing respectful maternity

The anticipated outcomes of this midwifery initiative are: Reduction in c-section rate from the current 61% to < 45% by 2023; Improved high risk categorization of pregnant women in all facilities with midwives; 50% of overall natural births in public health facilities are contributed by the midwives by 2023 and improved quality of care in all facilities. END