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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 90-93

Challenges faced by health workers in providing maternity management and family planning services in Assam


1 Research Consultant, International Union Against Tuberculosis and Lung Disease (The Union), Pune, Maharashtra, India
2 Department of Healthcare Management, Goa Institute of Management, Panaji, Goa, India

Date of Web Publication27-Oct-2015

Correspondence Address:
Janmejaya Samal
C/O - Mr. Bijaya Ketan Samal, At - Pansapalli, PO - Bangarada, Via - Gangapur, Dist - Ganjam, Pin - 761 123, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.168372

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  Abstract 

Background: The milieu of maternal health and family planning services always presents challenges in Indian communities. The situation is relatively more challenging in the rural parts of the country. The challenges are a mix of complex issues encompassing the health system and community challenges. Objectives: The basic objective of this study was to understand the challenges encountered by different cadres of health workers in providing maternity management and family planning services. Settings and Design: Different cadres of health care providers, that is, obstetrics and gynecology (O and G) specialists, medical officers (MOs), rural health practitioners (RHPs), and nurses working at the district and block levels were selected conveniently with the permission of State health administration.Materials and Methods: A qualitative pilot study was conducted in two districts of Assam. Participants were interviewed in-depth with the help of a semistructured interview schedule, which lasted for 26 days during May–July 2014. All the quantitative as well as qualitative data were entered and analyzed using Microsoft Excel. Results: It is evident from our observation that the set of challenges varies with the service provider as well as the category of services in maternity management and family planning. Lack of medicine, lack of manpower, and community dynamics are perceived to be the greatest challenges in providing services among three or six cadres of health care providers. In addition, poor patient compliance, lack of infrastructure, caseload, and inadequate training are also perceived to be major challenges. Conclusion: Many of these challenges are in fact obvious and articulated by many researchers, but it is what needs to be done to overcome these problems that is the most important issue.

Keywords: Challenges, family planning, health workers, maternity management


How to cite this article:
Samal J, Dehury RK. Challenges faced by health workers in providing maternity management and family planning services in Assam. J Health Res Rev 2015;2:90-3

How to cite this URL:
Samal J, Dehury RK. Challenges faced by health workers in providing maternity management and family planning services in Assam. J Health Res Rev [serial online] 2015 [cited 2019 Oct 15];2:90-3. Available from: http://www.jhrr.org/text.asp?2015/2/3/90/168372


  Introduction Top


The milieu of maternal health and family planning services always poses challenges in Indian communities. The situation is relatively more challenging in the rural parts of the country. The challenges are a mix of complex issues encompassing the health system and community challenges. The importance of maternal health has been strongly emphasized in the Millennium Development Goals (MDGs), which is the fifth MDG that lists "Improving maternal health."[1] The state of maternal health in India is also alarming, though the nation has seen improvement in the state of maternal health through decades of endeavor. Recent evidence shows that almost two-third (70%) of all illiterate women received no care, compared with 15% of literate women. Women in rural areas were much less likely to receive antenatal care (ANC) than women in urban areas (43% and 74%, respectively).[2],[3] It has been argued that the high levels of maternal mortality could be prevented if women had adequate health services, as in India the leading contributor to high maternal mortality ratios is lack of access to health care.[4],[5] Even today, India's maternal mortality rates in rural areas are among the world's highest. From a global perspective, India accounts for 19% of all live births and 27% of all maternal deaths.[6] It is stated that births that take place in nonhygienic conditions or births that are not attended by professionals are more likely to have negative impact on the mother and child.[7] Given the context, a qualitative study was carried out to understand the challenges faced by different cadres of health care providers in the state of Assam.


  Objectives Top


The basic objective of the study was to understand the challenges encountered by different cadres of health workers, that is, obstetrics and gynecology (O and G) specialists, medical officers (MOs), rural health practitioners (RHPs), and nurses in maternity management and family planning service delivery.


  Materials and Methods Top


Materials

A pilot qualitative study in two districts of Assam was carried out with the help of a semistructured interview schedule. The schedule consisted of questions pertinent to ANC, childbirth, postpartum care, family planning, abortion, referral services, monitoring and evaluation, and nonclinical duties.

Settings and design

Different cadres of health care providers, that is, O and G Specialists, MOs, RHPs, and nurses working at the district and block levels were selected conveniently with the permission of State health administration.

Methods

All the individual interviews were conducted at the respondents' respective health facilities after seeking written informed consent from them in English or Hindi as per the preference of each respondent. Each interview lasted for about 1–1.5 h. All the interviews were audio-recorded after obtaining consent for doing so from the respondents. The interviews were conducted with the help of a semistructured interview schedule that lasted for 26 days during May–July 2014. In total, 36 interviews were carried out: 6 O and G specialists, 9 MOs, 3 RHPs, and 18 nurses.

Data analysis

All the quantitative as well as qualitative data were entered and analyzed using Microsoft office excel – 2010 developed by Microsoft, USA. Descriptive statistical analysis was performed using frequency distribution table and bar graph.


  Results Top


Results were obtained regarding several areas of maternity management and family planning, including ANC, delivery services, postpartum care, family planning, abortion services, referrals or management of complicated/high-risk cases, nonclinical duties, and the monitoring and evaluation of health staff. For this purpose, six cadres of health providers were interviewed: O and G specialists, MOs, RHPs, and nurses [both auxiliary nursing and midwifery (ANM) and general nursing and midwifery (GNM)]. [Table 1] shows the responses of the different cadres of health providers facing challenges with respect to the delivery of different maternity management and family planning services. Similarly, [Figure 1] shows the number of responses to a particular challenge in providing maternity management and family planning services.
Table 1: Responses of different cadres of health providers facing challenges in the delivery of maternity management and family planning services

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Figure 1: Number of responses to a particular challenge while providing maternity management and family planning services

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  Discussion Top


While providing ANC services, all health care providers face one or the other types of challenges, except some nursing personnel; 50% of O and G specialists, 44.44% MOs, and 66.66% of RHPs face different types of challenges in providing ANC services. It was found that only 28.57% of nurses face challenges in providing ANC services, which is very low compared to other cadres of health providers. The reason might be nonrecognition of a particular challenge, or immunity to a particular challenge as a result of repeated exposure. Anemia as a specific disease burden has been perceived as an important challenge by MOs among several other challenges that are also common to nurses and RHPs. This was elicited during the interview process, as most of them referred to the wide prevalence of anemia among pregnant women requiring ANC services. This is a major public health challenge in rural India and requires prompt attention and wholesome intervention in terms of both medical measures, such as by distributing iron-folic Acid (IFA) tablets, and social measures, such as inculcating behavior change through rigorous counseling. Anemia during pregnancy is widespread throughout the globe, especially in rural areas, and is associated with an increased risk of maternal mortality.[8] Furthermore, a recently published meta-analysis has identified a significant reduction of 19% in the risk of low birth weight associated with the use of antenatal iron supplements.[9] Hence it is important to begin the daily oral intake of IFA as early as possible and continue it throughout the pregnancy.[10] During antenatal visits, the significance of IFA tablets should be repeatedly explained and enforced. Health education sessions should be conducted for pregnant mothers on a regular basis and the same implementation has to be percolated to all cadres of health service providers.[11]

Caseload has been perceived as a specific challenge in delivery (childbirth) and family planning services among MOs, which indicates poor distribution of health human resources, especially doctors. Despite the fact that the Indian health-care system has an intensive institutional network and the presence of diverse human resources, the public health system suffers from shortages, imbalances, maldistribution, poor work environments, low personnel productivity, numerous vacant posts, high staff turnover, loss of personnel to the private sector, and migration of workers to urban areas or overseas.[12] This problem can be suitably addressed by recruiting the required number of health workforce members and developing strategies to retain them within the health system. In providing delivery services, mostly medical doctors and nurses reported facing challenges, accounting for 66.66% and 50%, respectively. On the contrary, O and G specialists and RHPs face fewer challenges in providing delivery services. The challenges faced by nurses in delivery services indicate a complete health system challenge as they include manpower, drugs, and infrastructure as well. Thus to address this challenge, a complete approach is required. This may include management capacity building to plan, implement, and monitor programs; in addition, first referral units (FRUs) should be made fully functional, while the existing RHPs need to be strengthened by training, continuing medical education (CME) and skill development, improvement and maintenance of health infrastructure, and creating facilities for access to blood storage by pregnant mothers.[13]

In providing postpartum care, most of the health care providers do not face any challenge and is none for the rural health practitioners (RHPs). Usually there could be two different types of postpartum complications that include postpartum hemorrhage (PPH) and puerperal sepsis. PPH is the most common determinant of maternal morbidity and mortality. In developing countries, PPH continues to be a leading cause accounting for 25–43% of maternal deaths.[14],[15] In the process of interview a gynecologist expressed concerns about surgical intervention in PPH:

"[T] here are many guidelines available for the medical management of PPH but guidelines for the surgical intervention of PPH is not available and should be developed for the specialists."

(O and G specialist of a district hospital)

Furthermore, there are concerns associated with the availability of required manpower, drugs, and access to knowledge as well. This requires improvement in infrastructure as well as adequate supply of drugs and equipment, as hemorrhage has always been estimated to be the most important determinant of maternal mortality in India. In addition, PPH as a delivery complication has also been perceived as a major burden by some health providers (MOs and O and G specialists).

In delivering family planning services, most of the health care providers reported not facing any challenge. However, belief in charmers and faith healers by the community is perceived as a specific challenge by one of the RHPs.

"[P] eople, instead of coming to hospital for family planning services, visit the local healers, charmers, faith healers. This is more common among the minorities of this area."

(RHP of a health subcenter)

This indicates that the community needs strong health education and behavior change campaigns to make them eliminate less progressive social beliefs and taboos. In addition, inadequate training, as an important challenge in family planning service provision, is perceived by RHPs; it essentially needs to be addressed through the training of health workers to combat family planning-related problems in Assam. Again, failure in family planning service is an important concern; though the same is not rampant, but a petite of such problem may create distrust among communities on health system and may indicate toward medical negligence.

On the contrary, some of the services have been perceived as not challenging at all. These include abortion and nonclinical services by MOs and Health information system (HIS) and nonclinical services by nurses. This implies that mostly the nurses and the MOs are not involved in nonclinical-related activities, probably due to excessive workload in clinical areas or noninterest in the same. The nonchallenging nature of abortion services among MOs facade some skepticism, as abortion services involve a certain degree of technical skill, including the counseling of patients before an abortion and with postabortion complications. This implies that the MOs are either highly competent (this is probable) or not providing abortion services at all.

It is very much evident from our observation that the set of challenges varies with the service provider as well as the category of service in maternity management and family planning. Lack of medicine, lack of manpower, and community dynamics are perceived to be the greatest challenges in providing maternity management and family planning services among all the three cadres of health care providers. In addition, poor patient compliance, lack of infrastructure, caseload, and inadequate training are also perceived to be the major challenges. Poor patient compliance and community dynamics has been perceived as an important challenge by all health providers in providing maternity management and family planning services, which require strong interventions in terms of awareness and behavior change among the people of these communities; however, the number of providers who perceived any challenges related to family planning was quite low. On the other hand, the absences of facilities, infrastructure, manpower, medicine and equipment, and transport and communication facilities need to be addressed from the governmental end in collaboration with other relevant development sectors. Some of the MOs have also mentioned anemia as a disease burden among pregnant women seeking ANC services, which needs urgent attention as anemia has proved to be an important determinant of maternal mortality in the developing world including India; the same is true for PPH as a delivery complication. These conditions pose the greatest challenge at the two ends of gestation and contribute crucially to maternal mortality. These conditions need to be addressed with the following: Proper counseling; provision of IFA; provision of trained manpower such as obstetricians and anesthetists; necessary equipment; and blood storage facilities.


  Conclusion Top


This study was an attempt to articulate different types of challenges faced by health care providers currently working in the state of Assam in providing maternity management and family planning services. It was found that the number of health providers facing challenges and also the category of challenges were low for most of the health providers. The reason might be nonrecognition of or immune to a particular challenge owing to repeated exposure. Again, for many health care providers, revealing the limitations and challenges in service delivery might be an underestimation of their skills that lead to expression of confidence and concealing of challenges encountered. However, factors such as cultural beliefs and poor health-seeking behavior can be addressed by behavior change communication, motivation, advocacy, and communication, while the health system's flaws can be addressed by strong political will. Similarly the lacunae in skills and the motivation on the part of health care providers could be managed with proper training, orientation, and medical education.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

 
  References Top

1.
A/RES/55/2: United Nations Millennium Declaration: Resolution adopted by the General Assembly. 55/2. Sept 18, 2000. p. 9.  Back to cited text no. 1
    
2.
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), India, 2005-06. Madhya Pradesh, Mumbai: IIPS; 2008.  Back to cited text no. 2
    
3.
International Institute for Population Sciences. National Fact Sheet. India National Family Health Survey (NFHS)-3, 2005-06. Mumbai: IIPS; 2006.   Back to cited text no. 3
    
4.
Jejeebhoy SJ, Rao SM. Unsafe motherhood: A review of reproductive health. In: Gupta MD, Chen LC, Krishnan TN, editors. Women's Health in India: Risk and Vulnerability. Bombay, India: Oxford University Press; 1995. p. 1-15.  Back to cited text no. 4
    
5.
The World Bank. Improving Women's Health in India, Washington, DC. World Health Organization, 1996, "Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF," WHO/FRH/MSM/96.11, Geneva. 1996.  Back to cited text no. 5
    
6.
Saha UC, Saha KB. A trend in women's health in India – What has been achieved and what can be done. Rural Remote Health 2010;10:1260.  Back to cited text no. 6
    
7.
India Registrar General, 1996a, Fertility and Mortality Indicators 1993, New Delhi.  Back to cited text no. 7
    
8.
Murray-Kolb LE, Chen L, Chen P, Shapiro M, Caulfield L. CHERG iron report: Maternal mortality, child mortality, perinatal mortality, child cognition, and estimates of prevalence of anemia due to iron deficiency. Available from: http://www.cherg.org/publications/iron-report.pdf.[Last accessed on 2015 Aug 10].   Back to cited text no. 8
    
9.
Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi WW; Nutrition Impact Model Study Group (anaemia). Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: Systematic review and meta-analysis. BMJ 2013;346:f3443.  Back to cited text no. 9
    
10.
World Health Organization: Guideline: Daily Iron and Folic Acid Supplementation in Pregnant Women. Geneva: World Health Organization; 2012.   Back to cited text no. 10
    
11.
Mithra P, Unnikrishnan B, Rekha T, Nithin K, Mohan K, Kulkarni V, et al. Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of South India. Afr Health Sci 2013;13:880-5.  Back to cited text no. 11
    
12.
Sathpathy S, Venkatesh S. Human resources for health in India's national rural health mission: Dimensions and challenges. Regional Health Forum 2006;10:29-37.  Back to cited text no. 12
    
13.
Mavalankar DV, Vora KS, Ramani KV, Raman P, Sharma B, Upadhyaya M. Maternal health in Gujarat, India: A case study. J Health Popul Nutr 2009;27:235-48.  Back to cited text no. 13
    
14.
Tuncer RA, Erkaya S, Siphai T, Kutlar I. Maternal mortality in a maternal hospital in Turkey. Acta Obstet Gynecol Scand 1995;74:604-6.  Back to cited text no. 14
    
15.
al-Meshari A, Chattopadhyay SK, Younes B, Hassonah M. Trends in maternal mortality in Saudi Arabia. Int J Gynecol Obstet 1996;52:25-32.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]


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