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Preparing Midwives As a Human Resource for Maternal Health: Pre-Service Education and Scope of Practice in Gujarat, India

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Preparing Midwives As a Human Resource for Maternal Health: Pre-Service Education and Scope of Practice in Gujarat, India From : Department of Women‘s and Children‘s Health Karolinska Institutet, Stockholm, Sweden Preparing Midwives as a Human Resource for Maternal Health: Pre-service Education and Scope of Practice in Gujarat, India Bharati Sharma Stockholm 2014 All previously published papers were reproduced with permission from the publisher. Published by Karolinska Institutet Printed by Universitetsservice US-AB © Bharati Sharma, 2014 ISBN 978-91-7549-657-3 Department of Women‘s and Children‘s Health Division of Reproductive Health Preparing Midwives as a Human Resource for Maternal Health: Pre-service Education and Scope of Practice in Gujarat, India DISSERTATION For Doctoral Degree (Ph.D.) at Karolinska Institutet The public defence will be held at Lecture room Samuelsson, Tomtebodavägen 6, Solna Campus, Stockholm At 9.00 a.m. on Monday, 29th September 2014 by Bharati Sharma Principal Supervisor: Opponent: Professor Kyllike Christensson Professor Tina Lavender Karolinska Institutet Manchester University Department of Women‘s and Children‘s Health School of Nurses and Midwives and Division of Reproductive Health Social Work Co-supervisor(s): Examination Board: Professor Eva Johansson Professor Maria Emmelin Karolinska Institutet Lund University Department of Public Health Department of Social Medicine & Global Health Division of Global Health Professor Eva Nissen Professor Dileep Mavalankar Karolinska Institutet Institute of Public Health Gandhinagar Department of Women‘s and Children‘s Health Gujarat, India Division of Reproductive Health Dr. Malavarappu Prakasamma Docent Siw Alehagen Academy of Nursing Studies and Linköpings University Women‘s Empowerment Research, Department of Medical & Health Science Hyderabad, India ABSTRACT One key strategy to achieve reduction in maternal and neonatal mortality is to scale up the availability of skilled birth attendants (SBAs). The staff nurses (i.e., registered nurse and midwives) are skilled birth attendants recognized by the government of India. Aim and objectives: This thesis studied women‘s choices, perceptions, and practices related to childbirth, and how these were affected by modernity in general and modernity brought in by maternal health policies (Paper-I). The midwifery scope of practice of staff nurses was studied in government facilities (Paper-II). The confidence of the final-year students on selected midwifery skills, from the diploma and bachelor‘s programmes, was assessed against the list of competencies of the International Confederation of Midwives (ICM) (Paper-III). The teaching and learning approaches associated with confidence were also studied (Paper-IV). Methods: The grounded theory approach was used to develop models for describing the transition in childbirth practices amongst tribal women (Paper -I) and to describe the scope of midwifery practice of staff nurses (Paper-II). Data used for Paper-I included eight focus groups with women and five in-depth interviews with traditional birth attendants and staff nurses. For Paper-II, 28 service providers and teachers from schools of nursing were interviewed in depth. A cross sectional survey design was used to assess the confidence of final-year students from 25 randomly selected educational institutions stratified by type of programme (diploma/bachelor‘s) and ownership (private/government) (Paper-III & IV). Students assessed their confidence using a 4-point Likert scale in the competency domains of antepartum, intrapartum, postpartum, and newborn care. Explorative factor analysis using principal component analysis (PCA) was used to reduce skill statements into subscales for each domain. Crude and adjusted odds ratios with 95% CI were calculated to compare students with high confidence (≤75th percentile of scores) and those without high confidence (> 75th percentile) to compare diploma and bachelor students (Paper-III) and to study the association of teaching-learning methods and high and not high confidence for each subscale (Paper -IV). Results: A transition in childbirth practices was noted amongst women—a shift from home to hospital births seen as a ‗trade-off between desirables (i.e., secure surroundings) and essentials (i.e., reduced risk of mortality)‘ (Paper-I). General development, increased access to western medical care, and international/national maternal health policies socialized women into western childbirth practices. The communities increasingly relied on hospitals as a consequence of role redefinition and deskilling of the Traditional Birth Attendants. Existing cultural beliefs facilitated the acceptance of medical interventions. The midwifery practice of staff nurses was ‗circumstance-driven‘ and ranged from extended to marginal because the legal right to practice was unclear Paper-II). Their restricted practice led to deskilling, and extended practice was perceived as risky. The clinical midwifery education of students was marginalized. Because of dual registration as nurse and midwife, the identity of a nurse was predominant. From 633 students, 25-40% scored above the 75th percentile and 38-50% below the 50th percentile of confidence in all subscales Paper-III). A majority had not attended the required number of births prescribed by the Indian Nursing Council. The diploma students were 2-4 times more likely to have high confidence in all subscales compared to the bachelor students. High confidence was associated with number of births attended, practice on manikins, and being satisfied with supervision during clinical practice (Paper-IV). Conclusions: Access to hospitals increases women‘s choices for childbirth in the context of high mortality. Inequitable distribution of health facilities requires region specific strategies. The women are dissatisfied with the psychosocial aspects of hospital care. India has a national regulatory body, but midwifery specific regulation is lacking. In this situation, the midwifery scope of practice of staff nurses is undefined. The pre-service midwifery education does not develop student‘s confidence to provide first level care for childbirth, as expected by the governments. Short-term and long-term measures to professionalize midwives in India are suggested. Key words: Midwifery scope of practice, midwifery regulation, pre-service midwifery education, staff nurses, childbirth, India PREFACE The research group at the Centre for Management of Health Services (CMHS) at the Indian Institute of Management Ahmedabad (IIMA) in Gujarat has been active in health systems, health management, and policy research for maternal and child health. The research questions included in this thesis emerge from the involvement of CMHS in a Sida-supported collaborative project with the Karolinska Institute from 2006 to 2013. India has high maternal and newborn mortality rates and an almost non-existent midwifery profession. Sweden was successful in rapid reduction in its maternal mortality historically, with a competent midwifery workforce in spite of low resources at the time. This project was developed for India to learn from the midwifery profession in Sweden. Sida brought in Sweden‘s strength and expertise in midwifery through the involvement of the Karolinska Institute, the Swedish Association of Midwives, and in the later phases the Uppsala University. The Indian partners included organizations working for and representing midwives such as the Academy for Nursing Studies and Women‘s Empowerment Research (ANSWERS) and the Society of Midwives of India (SOMI). The Trained Nurses Association of India (TNAI), which represents nurses in India, was also a partner. The other Indian partners were the White Ribbon Alliance of India and IIMA. The aim of the project was to strengthen the profession of midwifery in India for good quality basic childbirth services. The situation analysis studies undertaken as part of the project identified several gaps in the education, practice, and regulation of midwives. These have been documented in the IIMA monograph [1]. Very few studies before this were undertaken for understanding maternal health and midwifery together. The set of studies included in this thesis delve deeper into the factors that determine the role of midwives in maternal health in India. They add to the contribution made by the Midwifery Strengthening Project and towards strengthening the midwifery profession in India. LIST OF SCIENTIFIC PAPERS I. Sharma Bharati, Giri Gayatri, Christensson Kyllike, Ramani KV, Johansson Eva: The transition of childbirth practices among tribal women in Gujarat, India - a grounded theory approach. BMC International Health and Human Rights 2013, 13(41). II. Sharma Bharati, Johansson Eva, Prakasamma Mallavarapu, Mavalankar Dileep, Christensson Kyllike: Midwifery scope of practice among staff nurses: A grounded theory study in Gujarat, India. Midwifery 2013, 29 628–636 III. Sharma Bharati, Hildingsson Ingegerd, Johansson Eva, Ramani KV, Prakasamma Mallavarapu, and Christensson Kyllike: Do the pre-service education programmes for midwives in India prepare confident Skilled Birth Attendants? A survey from one district in India.(Submitted). IV. Sharma Bharati, Hildingsson Ingegerd, Johansson Eva, Ramani KV, Christensson Kyllike: What are the teaching-learning methods contributing to the confidence of midwives during pre-service education? A survey from Gujarat, India. (Submitted) CONTENTS 1. BACKGROUND 1 1.1 Maternal health and midwifery a global perspective……………………………… 1 1.1.1 Maternal and Neonatal mortality……………………………………….. 1 1.1.2 Maternal health initiatives………………………………………………
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