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Home >> Evaluation/Research >> Safe Motherhood in Bangladesh
 Thematic Review of Safe Motherhood in Bangladesh

Executive Summary

The health and family planning programme of Bangladesh has made remarkable progress in the last two decades as evident from the decline in fertility rate, infant and child mortality rates. The reduction in maternal mortality in the past 15 years is 22%, right on target towards Millennium Development Goal (MDG) of a 75% reduction between 1990 and 2015. However, the Maternal Mortality Ratio (MMR) is still high (320 per 100,000). Haemorrhage is the leading cause of death followed by eclampsia. Low level of awareness about complications during pregnancy, poor access to quality EmOC facilities particularly in the rural areas and economic barriers to accessing care are reported as some of the important contributory factors to the high level of maternal mortality. An important contributory factor to the high level of maternal mortality, the Total Fertility Rate (TFR), has declined to 3 after a decade of stagnation at 3.3 (Bangladesh Demographic and Health Survey (BDHS) 2004). There are marked differentials in MMR and TFR rates between the divisions, the rates being highest in Sylhet and Chittagong. The differentials between different economic quintiles are also marked. The recent data from the BDHS shows that while there is an increase in antenatal care by skilled providers, there is no improvement in proportion of deliveries conducted by skilled attendants (14%). The proportion of institutional deliveries is woefully low (10%). The data also shows that the low level of postnatal care continues. The Contraceptive Prevalence Rate (CPR) has increased to 58% (modern methods) (an increase by 4%), however the proportion of users of the long acting methods have remained stagnant and the high drop out rates continue. These findings have major implications for maternal mortality reduction programmes. The Government of Bangladesh (GoB) has developed several strategies to improve the access to skilled care and to Emergency Obstetric Care (EmOC), especially by the poor.

The main objective of the thematic review of the quality of safe motherhood services is to identify areas for future programme strengthening to create an enabling environment for improved utilisation of services by the poor. The framework for the review focused on rights of clients and needs of providers. Key elements that are critical for enabling the realisation of the rights, especially by poor women, such as policy framework, decentralisation, quality assurance mechanisms and human resource development and the role of NGOs and private sector have also been reviewed.

The summary of findings and recommendations are given below.

1. Policy framework

The National Maternal Health Strategy is built on rights framework and is based on the 'three delays' model. Reduction of maternal mortality is one of the major goals of the Poverty Reduction Strategy and Health, Nutrition and Population Sector Programme (HNPSP) indicating the commitment of the GoB. However, there are gaps in terms of resource allocation for EmOC. Recommendations
  • Using the digitised enumeration maps developed by Bangladesh Bureau of Statistics (BBS) (with UNFPA assistance under the Sixth Country Programme (CP), the current and planned availability and distribution of EmOC facilities should be reviewed. The information should be used for planning of facilities.
  • Consideration should be given to increasing budget allocations to meet the gaps in number and distribution of EmOC facilities to ensure access within a maximum time of two hours.
  • The HNPSP human resource development plan should pay special attention to availability of doctors and nurses trained in EmOC (see more under section 3.4 'human resource development).
2. Decentralisation and local level planning

The current efforts at decentralisation of the HNP sector include activities for maternal mortality reduction. Recommendations
  • Advocacy efforts should be directed at the HNP service development committees to
  • increase budgetary allocations for EmOC facilities
  • improve human resource availability for safe motherhood (including Family Planning (FP) and Reproductive Tract Infections (RTI) / Sexually Transmitted Infections (STI). This should contribute to achieving the targets in reduction of maternal and infant mortality. With increasing number of women especially the poor having access to facilities, equity and gender equality should also improve.
  • The management skills of the District and Upazila health managers should be strengthened which should contribute to improving the efficiency of the health system and thereby the efficiency of the EmOC services, as it is inextricably linked to the former.
3. Quality assurance (QA) systems

Various quality assurance mechanisms are being implemented by the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP) as well as by the Urban Primary Health Care Project (UPHCP). Maternal death audits and clinical audits are being practised by some of the Medical Colleges. However, the systems need strengthening. Recommendations

The following recommendations are made in the context of the HNP Sector Investment Plan that promotes a health system that is more responsive to clients' needs, efficient and effective in reaching the services to the poor.
  • HMIS
    • The proposed strengthening of the Health Management Information System (HMIS) by the DGFP and DGHS under HNPSP should provide an opportunity to institute mechanisms to ensure that the reports are reviewed and appropriate actions are taken. This is also important for performance planning as envisaged under the HNPSP.
    • The labour room and client records should be reviewed to add columns or subtitles to ensure that relevant information is collected. In addition, the maternity ward registers, death records and general statistical records of female patients should be reviewed and modified appropriately. The Maternal and Child Welfare Centres (MCWC) reports should include information on complications (linked to recommendations on HMIS under section 3.9 'right to continuity of care').
    • The reporting on EmOC indicators developed under the 'Women's right to life and health' project should be strengthened. It is important to ensure that the definitions are well understood by the institutions.
  • Review of the QA instruments and system should be done to ensure regularity and follow up actions based on the findings of the monitoring visits.
  • The quality and coverage of the maternal death reviews should be strengthened with the ultimate objective of reducing maternal deaths and improving the quality of care and not for punitive action. Perinatal death reviews also should be instituted. Training programmes should be instituted to systematically introduce facility-based maternal death and perinatal death reviews . Since substantial number of maternal deaths takes place at home, a system of verbal autopsy should be introduced (ICDDR, B is an excellent resource). The community based SBAs should be trained in the technique. 'Near miss audits' introduced under the 'Women's right to life and health' project should be strengthened. Clinical audits should be instituted in health facilities (see details under section 3.6. 'right to safe services') based on the gaps identified during maternal death reviews.
  • Community audits of maternal deaths by women's groups should be encouraged to monitor the quality of care provided at institutions or at home. Such audits also build accountability of the health system.
  • The composite score used under the urban project should be reviewed.
  • As part of the monitoring process being developed under HNPSP and the decentralisation process, quality assurance circles (building on the existing ones) should be developed. These circles will ensure the quality of various service components of safe motherhood. This will also help to bring accountability as the HNP service development committees include community stakeholders.
  • All activities on QA should be linked to the QA system being developed under the HNPSP.

    These recommendations reinforce the action plans of maternal health strategy.

    4. Human resource for safe motherhood

    The national maternal health strategy includes a human resource plan to support safe motherhood services. Although the action plans of DGHS and DGFP under HNPSP recognises reduction in maternal mortality as one of the focus areas, the human resource development planning has no specific focus on human resources for safe motherhood. As per the strategy, several categories of providers from the peripheral facilities have been trained in EmOC. Currently the training of community based Skilled Birth Attendants (SBAs) and training in midwifery of the Family Welfare Visitors (FWVs) are underway. Recommendations
    • Decision should be taken on the duration of the EmOC training of Doctors.
    • The excellent training materials developed for the four months course training and the methodologies should be used for training, irrespective of the final decision on the duration of training.
    • Regulation on scope of practice of various categories of providers should be clearly defined. The Bangladesh Nursing Council (BNC) should take a lead on this issue.
    • Quality assurance in training through follow up and clinical audits should be developed (see also under section 3.3 'quality assurance').
    • See recommendations for SBA training and FWV training under section 3.11 on 'staff need for information, training and development'.
    • An updated human resource plan for safe motherhood should be developed and should be part of the HNPSP plan (as recommended under the 'policy framework'). The plan should include the proposed posting of junior specialists in Upazila Health Complexes (UHCs).
    5. Client's right to information

    Information contributes to empowering women to participate in decision-making and enable them to exercise their right to care. The GoB has implemented several strategies to increase awareness about FP and safe motherhood and it has paid dividends as evident from the increase in knowledge levels. However, there are still information gaps on key issues such as the awareness about danger signs during pregnancy and birth preparedness plan, critical for overcoming the delay in seeking care and delay in reaching a health care facility. Other critical information gaps are knowledge about side effects of contraceptives (a major reason for high drop out rates), dual protection with condoms and STIs.

    Recommendations

    Stimulating demand for services is one of the seven challenges/ strategies identified under the HNP Sector Investment Plan.
    • The information campaigns should be complemented with evidence based strategies for BCC for key decision makers in the family and community (using ongoing effective strategies or developing new ones). The aim is to make " every pregnancy special" and ensure that a woman's right to safe pregnancy and delivery is ensured. These efforts should be linked with the various BCC activities being undertaken by various agencies and the proposed Behavioural Change Communication strategy with UNFPA assistance. The focus of these should be on complications of pregnancy, birth preparedness planning (see details below), skilled birth attendants at delivery and gender-based violence particularly during pregnancy.
    • The capacity of the BCC workers under the UPHCP in interpersonal communication should be strengthened. A system should be developed through which the BCC workers discuss with families the information provided under the public information campaign.
    • Regular health education in ANC, maternity wards and postnatal clinics on care of mother and newborn, birth planning, FP and STI/HIV and gender based violence should be provided (as appropriate).
    • The health education sessions should ensure "two way communication' to enable clients to clarify doubts. Such an approach will also help health educators to assess whether the clients understood the messages. Consider including the topic during training.
    • Posters and leaflets on topics identified above especially on danger signs during pregnancy, skilled birth attendants at delivery, side effects of contraceptives and dual protection, presented in a manner that is easily understood by an illiterate person, should be made available in all health facilities. Such health education material should be displayed in community facilities (as appropriate) as well as in groups organised by women's development programmes.
    • The knowledge of the Family Welfare Assistants (FWAs) and Female Health Assistants (FeHAs) (in wards and villages where no community based SBAs are available) and FWVs and Nurses in UHCs, Upazila Health and Family Welfare Complexes (UHFWCs) and UPHCP centres should be improved to promote birth preparedness planning (The training of community based SBAs does include information on birth preparedness planning). The birth preparedness plan should identify the skilled birth attendant, preparation for home delivery, transport, emergency funds and location of EmOC facility.
    • During home visits, the field workers should hold sessions on birth preparedness planning that includes the key decision makers in the family. The planning should ideally include the birth attendant the family traditionally uses and the practitioner (if applicable) to ensure their support in referral of cases during complications (this is important as often the birth attendants/ practitioners delay the referral in case of complications).
    • The lessons learned from the CARE Dinajpur Safe Motherhood Initiative and other similar community mobilization initiatives for safe motherhood should be reviewed and replicated elsewhere. Linkages should be established with the existing women's groups to foster partnership with them to help women realize their right to safe pregnancy and delivery. Such a partnership will help women to access information on topics identified above and access services.
    6. Clients' right to informed choice

    The quality of FP counselling is poor and it is difficult to comment whether the choice is based on 'a well considered decision' that is based on information and understanding. The influence of provider bias in choice of method was difficult to assess. Recommendations
    • The quality of counselling services should be improved by strengthening the skills of providers in counselling in various situations (discussed under the section on 'provider need for information, training and development') and by providing full information on the topic of concern.
    • FP counselling should include information on all methods available, advantages and disadvantages, side effects, action to be taken in case of missing dose and provision of condoms for back up protection and for dual protection if at risk. In case of IUDs and surgical contraception, counselling after the procedure is equally important.
    • As identified earlier in case of STI clients, focus should be on prevention of future infections, increased risk of HIV, importance of taking full course of treatment, follow up, partner counselling and treatment.
    • Clients of post-abortion care should be counselled for FP. The information shared should focus on the risk of immediate conception if no FP is used and the methods that are most suitable for immediate use and for use after a prescribed duration of time.
    Counselling helps duty bearers (health service providers) to enable rights-holders (clients) to realise their rights.
  • In case of non-emergency situations, a system of counselling clients before obtaining consent for procedures should be initiated. However, in case of emergencies, stabilisation of clients should be done first.
  • Information on importance of voluntary donation, screening of blood and obtaining safe blood should be provided to key decision makers of the families of clients needing blood transfusion. This is critical since the most common practice in UHCs and MCWCs and private sector is obtaining blood from private blood banks for women who need transfusion.

    WHO's Decision making tool for FP clients and providers is a very useful tool for promoting informed choice.

    7. Clients' right to access to services

    The continuing disparities in access to maternal health services by income status, with women belonging to the lower economic quintiles having poor access to reproductive health care especially EmOC is a concern. Although the access to antenatal care is good, the utilisation is poor as evident from the data presented earlier. The major access issues are access to skilled care during home deliveries and in institutions after hours. The other issues are poor linkage with nutrition programmes for improving the nutritional status of the undernourished pregnant women, poor access to laboratory services for STI diagnosis and safe blood transfusion services. Postpartum FP is not actively promoted. Cost is a major barrier to accessing the public sector services. The other social barriers are lack of decision- making power even when women have the knowledge about the importance of accessing care.

    Recommendations

    Safe motherhood
    • Recommendations under 'right to information' should contribute to improving antenatal care and postnatal care as well as deliveries by skilled birth attendants.
    • Review of human resources in the health facilities should be done to ensure that skilled care is available round the clock in District Hospitals (DHs) and UHCs.
    • The SBA training should be expanded to cover all the Upazilas in the districts where the training has started and then to other districts, giving priority to districts with high maternal mortality. Consideration should be given to starting the training programme in urban areas.
    • The linkages with nutrition programmes should be strengthened. A system of referral of poor and malnourished women to the nutrition centres should be developed. The linkage with nutrition programmes is also one of the actions listed under the maternal health strategy.
    • EmOC facilities
  • Expand access to EmOC by strengthening facilities for provision of EmOC services as envisaged under the HNPSP beginning with high mortality divisions. All the UHFWCs should be strengthened to provide obstetric first aid.
  • While expanding the access, all efforts should be made to ensure the continuation of the EmOC services being provided by the designated facilities. The EmOC monitoring format used by the DGHS and the reports from MCWCs should be reviewed regularly and action should be taken to fill the gaps. The format should be reviewed to ensure that information on availability of all signal functions of BEmOC is available. The clinical and managerial reasons for the gaps should be rectified (linked to the recommendations under 3.3. quality assurance).
  • Human resources for safe motherhood should be reviewed critically. The current needs and projected needs should be estimated and should be part of the HNPSP plans (see under sections 3.1 and 3.4 'policy framework and human resource development'). The availability of skilled attendants round the clock should be one of the factors considered while developing the plan.

    FP
    • Postpartum FP services should be strengthened in all the facilities. FP should be actively promoted during domiciliary postnatal visits.
    • The quality of counselling services should be strengthened (details under the section "right to informed choice"). Dual protection using condoms should be actively promoted.
    • A system of follow up of clients should be instituted to track clients on oral contraceptives and injectables who discontinue the method. This could be easily achieved by modifying the existing FP recording system (linked to section 3.9 'right to continuity of care'.
    • A directive should be sent out from the DGFP clarifying the issue on registration of facilities under the City Corporation for receiving free FP supplies. Since these facilities cater to the poor urban slum dwellers, access to free services and supplies will contribute to increasing the use of FP methods.
    • Availability of emergency contraception should be expanded to the rural areas after adequate training.
    RTI/STI services

    • The syndromic management of RTI/STI services should be further strengthened. The treatment facilities should be extended to all the UHCs. The UHFWCs should be strengthened as per national policy to provide RTI/STI services.
    • Counselling and partner notification and treatment should be strengthened.
    Laboratory facilities
    • The laboratories in the DHs and UHCs should be strengthened for aetiological diagnosis of selected RTIs/STIs. (also discussed under recommendations in the section on 'right to supplies, equipment and facilities).
    • Consider starting laboratory facilities in MCWCS to improve access to RTI/STI services.
    Blood transfusion facilities
    • As per national policy on blood safety, blood-banking facilities should be developed in all the DHs with priority given to districts where EmOC services are being strengthened.
    • Stringent quality assurance mechanisms for safe blood should be instituted as articulated in the National Strategic Plan for HIV/AIDS.
    Economic barriers
    • Based on the findings of the evaluation of the pilot projects on maternal health voucher scheme, the scheme should be expanded to other areas. Close monitoring of the beneficiaries of the scheme is important and women's groups can play a major role in this. While introducing the scheme, it is also important to ensure that the beneficiaries are aware of their entitlements under the scheme.
    • Community saving /insurance schemes Ø Through women's groups or through other community mobilisation efforts, women from poor families should be encouraged to save for emergencies - pooling of funds is an option. Community insurance scheme and BRAC's micro-health insurance scheme are other options. In case of community insurance schemes, t is important to ensure that poor families are not excluded and that women with complications do have access to the funds.
    • Facilities visited had a functioning ambulance, however the availability of the transport 24 hours is a concern. Mostly the ambulance is available for transporting patients to a higher facility and less likely for transferring patients from home. Efforts should be made to identify community transports that are available 24 hours for transporting emergencies. The form of transport may vary according to the local situation. Mechanisms for paying for the transport should be developed in advance.
    Social and gender related barriers
    • Active partnership with community-based organisations should be fostered to overcome some of the social and gender related barriers listed under findings. Experiences from the CARE Dinajpur project has shown clearly that social mobilisation efforts facilitate participation and inclusion of women in decision making and utilisation of services.
    • Although there were no reports of health service provider attitudes being a deterrent to accessing care, all training of health service providers should include the importance of positive attitude towards women, particularly the poor who utilise the services.
    • As recommended under section 3.5, the traditional birth attendants and practitioners should be involved in the birth preparedness plan.
    8. Client's right to safe services

    Standards are essential for delivery of safe services. Although standards for safe motherhood services especially management of obstetric complications have been developed, they were not available in the facilities. Evidence-based management of normal and complicated labour and delivery such as use of partograph to monitor labour, active management of third stage of labour, use of Mag. Sulf for management of eclampsia, assisted vaginal delivery and removal of retained products of conception using Manual Vacuum Aspiration (MVA) technique were not being followed in most of the facilities, however the case management practices are better in MCWCs and UPHCP facilities. Obstetric first aid is not available in any of the UHFWCs. Infection prevention especially waste disposal is another area of concern. Clinical audits are practised in some of the teaching institutions. Referral guidelines for referring obstetric and neonatal complications are not available. Recommendations
    • Written standards should be available in all the health facilities. The existing guidelines and the MCWC operational manual should be reviewed and updated or modified to set clinical standards for health facilities at various levels. From the SBA'S reference manual, standards for home deliveries should be developed. The standards at various levels of health care should be well linked. The standards should include immediate care of the newborn and readiness of facilities for emergency care. In addition, standards for facility management and for protecting the rights of clients should be developed. The recommendation is also one of the actions under the maternal health strategy.

      WHO's safe motherhood publications, listed below, are useful resource materials. i. Integrated Management of Pregnancy and Childbirth: Managing complications of Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO Geneva. (this is already available in Bangla).

      ii. Integrated Management of Pregnancy and Childbirth: Essential Care Practice Guide for Pregnancy, Childbirth and Newborn Care. WHO Geneva.

      iii. Managing newborn problems: Guide for doctors, nurses and midwives, WHO Geneva.
    • Involvement of professional associations in the development of guidelines should be ensured for promotion of adherence to the guidelines.
    • Partographs should be introduced in all UHCs and the process should be reactivated in DHs. The staff should be oriented to the importance of maintaining the partograph in all labour cases and the importance of timely action to prevent maternal deaths and morbidity. The review of partographs should become part of the quality assessment tools.
    • All efforts should be made to institutionalise active management of third stage of labour.
    • The capacity of the MCWCs, UHCs and UPHC centres and selected DHs should be strengthened to provide immediate newborn care and management of complications of newborns.
    • The flow charts for management of obstetric and neonatal complications should be displayed in all the labour rooms.
    • Mechanisms should be developed to ensure that EmOC trained staff (Nurses and Doctors) are available round the clock every day of the week.
    • Guidelines for referral of obstetric and neonatal emergencies should be developed which should include instructions on critical elements such as stabilising the patients before referral, communicating in advance with the facility where the client is being referred, care during transportation, relevant medical records and referral note.
    • Management of emergencies and referrals as per guidelines should be instituted and adhered to in all the facilities.
    • All six signal functions of BEmOC should be made available as recommended in the section ' right to access to services'.
    • The recommendations on safe blood supply are given under the section ' right to access to services'.
    • The UHFWCs should be strengthened to provide obstetric first aid.
    • Counselling on FP of post-abortion clients (with emphasis on early return to fertility) should be strengthened.
    • The importance of counselling while providing emergency contraception should be emphasised to the staff of the facilities where the method is being introduced. Although standards for FP methods exist, it should be ensured that infection prevention during procedures and dual protection with condoms are emphasised.
    • The infection prevention practices in all the facilities should be strengthened and adequate supplies for the same must be ensured.
    • Clinical audits should be instituted in as many facilities as possible. These should be undertaken by teaching institution staff . Availability of standards is a pre-requisite for clinical audits. The aspects of care that is deficient as identified from maternal and perinatal death reviews should be audited. The audit should contribute to ensuring that the practice in hospitals are governed by the standards and protocols developed. Complete case records are essential for the process. The private sector should be also audited using the same tools.
    • Quality improvement processes such as COPE and facility audits should be instituted within institutions so that problems are identified and action is taken (linked to recommendations on quality assurance circles).
    • The quality of menstrual regulation services should be monitored. Counselling of clients prior to and after the procedure especially for FP is critical to prevent immediate conception (due to early return of fertility) and another procedure. Infection prevention during the procedures should be strictly adhered to.
    3.9. Clients' right to continuity of care

    Vital signs of postpartum clients at prescribed intervals are not checked regularly. Follow up of FP clients and STI clients is not satisfactory. Management of referrals is not satisfactory. Recommendations
    • The training in FP should emphasise the importance of providing information on warning signs, care after IUD insertion, surgical contraception and what action to be taken by the client as well as the health service provider an follow up. The importance of post-abortion clients being followed up for provision of FP should be included in the training (stress the early return of fertility and chances of another pregnancy if no contraception is used).
  • Institute mechanisms for follow up of clients.
    • The clients should be provided information on when to return for follow up services/ supplies. The importance of follow up visits /check ups should be emphasised to pregnant women and postpartum women.
    • The current HMIS should be reviewed to assess whether it is possible to track clients. The tracking should help to identify defaulters in case of FP spacing methods, women who are due to deliver (to reinforce birth preparedness plan and to provide postnatal care as early as possible) (linked to the recommendation under section 3.8 right to safe services).
    • The discharge slips should be modified to include full information about significant history and examination findings and treatment provided, what treatment / care should be continued at home, what to watch for, when to return for follow up.
  • Follow up of STI clients should be strengthened as well as treatment of their partners.
  • The referral system should be strengthened.
    • Referral guidelines should be developed as discussed under the section ' right to access to safe services'.
    • Referral slips should be developed that includes a section on feedback, preferably detachable, that can be sent through the client or relative to the facility that referred the client.
    • The providers in the referral facilities should be oriented to the importance of feedback to the referring facility on diagnosis and management of the case or on follow up treatment. This should help in follow up of referred clients.
    • Linkages should be established with private /NGO hospitals where specialist services are available. However, it is important to ensure that the facility provides quality care. Mechanisms for reimbursement of costs in case of poor patients should be spelt out while establishing the linkages.
    • The facility that is referring should assist with arrangements for transportation of the patients either through the health facility ambulance or a community transport (see recommendations under section 3.7 'access to services').

      10. Clients' right to privacy and confidentiality and

      Clients' right to dignity, comfort and expression of opinion

      Maintenance of privacy in FP clinics and labour rooms is not satisfactory. Patients are not provided opportunities to express their concerns, which is critical for improving services.

      Recommendations
    • Privacy and confidentiality should be improved by changing the attitude of staff through training. Such training should use well-designed role plays that will help the staff understand the "client's feelings' and thus realise the importance of these elements of care. This aspect of care should be regularly monitored.
    • A system of feedback from clients should be instituted to improve the quality of services. Such a system would ensure that patients whom the system is supposed to serve understand their entitlements (right to information, informed choice, access to services and safe services) and create an enabling environment to demand them. In such an environment, providers will be obliged to follow standards.
    • Client/stakeholder involvement should be encouraged using the lessons learned from the various projects in the country.

      11. Staff need for information, training and development

      Training of Medical Officers and Staff Nurses, Laboratory Technicians and Blood Bank Technicians (from MCWCs and selected UHCs) to upgrade facilities to provide EmOC services has been done. The training in counselling is not satisfactory. SBAs receive competency-based training. FWVs are being trained in midwifery and Nurses from selected facilities receive training in standards of midwifery care. Follow up training is a major gap. Recommendations

    • Staff at all levels including district hospitals (as needed) should be trained in immediate care of newborn.
    • All staff should be trained in diagnosis and management of gender-based violence as part of EmOC training and linked with ongoing UNICEF and NGO efforts.
    • Midwifery skills of all nurses posted in district hospitals, UHCs, MCWCs and UPCP facilities should be strengthened through short courses. It may be worth considering permanent posting of nurses interested in midwifery in the labour rooms.
    • The training of nurses in midwifery standards should be expanded to all the facilities.
    • The DH specialists should be oriented to gain their support in the implementation of the EmOC standards.
    • The FWV training should be reviewed in the context of the community-based SBA training.
      • The training should include selected BEmOC skills so that UHFWCs can start providing such services as envisaged under the HNPSP plans as discussed under section 3.1 'policy framework'.
      • The training also should include skills in supportive supervision (see also under section 3.11 ' staff need for facilitative supervision and management'.
    • Both the SBA and FWV training should be institutionalised (as discussed under the background section, the training of SBAs is not institutionalised).
    • The trainees should be followed at their worksites. Follow up of trainees is essential to assess the retention of skills and the quality of services provided. A sample of trainees should be followed up. The training follow up guidelines given in the training management guidelines should be implemented. Plans for follow up of other trainings also should be developed. A well-defined plan for follow up should be part of any training design. Adequate funds should be included for the same.
    • The community based SBA training programme should have a follow up plan for the batches that have been trained / undergoing training and for the new batches that will be trained. The plan should include when the follow up will take place, who will do the follow up, guidelines for follow up, reporting and what remedial actions to be taken in case of gaps in skills or other problems that affect the quality of care. Funding should be provided for follow up.
    • A master plan for training of community-based SBAs that includes their follow up should be developed. This should be linked to the training plans and training management information system being developed under HNPSP.
    • The job description of the SBAs should be developed by reviewing and modifying the current job descriptions of the FWAs and FeHAs.
    • BNC's capacity and capability (managerial and technical) should be strengthened to monitor the quality of the training of SBAs and FWVs and also follow up of trainees. Seconding of competent staff from training institutions to BNC is an option that should be explored.
    • Involvement of professional organisations in providing training support. Such involvement will create a supportive environment for mentoring the staff trained in EmOC and Anaesthesia.
    • OGSB should expand its role to support continuing education of doctors in EmOC. It should continue to play an active role in the training of SBAs, especially in the evaluation and the modification of training materials. It should provide inputs into the review and revision of the FHV training in midwifery and support the BNC in midwifery training of nurses.
    • The professional societies of anaesthesia and neonatology should be actively involved.

    12. Staff need for facilitative supervision and management

    The system of supervision is weak. The decision on supervisors of SBAs is not available.

    Recommendations

  • Supportive supervision needs to be strengthened at all levels.
    • Besides training supervisors, it is also important to develop supervisory checklists that can be used by the supervisors for monitoring and the next level of supervisors.
    • The technical skills of supervisors need to be strengthened to enable them to assess the quality of services as well as mentor the staff they supervise.
    • The supervision should include (but not limited to) review of protocols to ensure that workers understand them, review of records to see the coverage of services and discussions on gaps, importance of infection prevention and privacy and confidentiality. Clinical audit is a good tool to teach staff.
  • The managers of health facilities need orientation in importance of quality improvement and the need to support staff in various quality assurance activities. The support of managers is critical in infection prevention, ensuring privacy and functioning equipment. The managers also should institute a system of recognising staff who perform well
  • The recommendations under 'quality assurance' are also applicable to strengthening supportive supervision and management.
  • As more community based SBAs are being trained and posted, it is critical to identify and train the supervisors. This should be done on a priority basis.

    13. Staff need for supplies, equipment and infrastructure

    Shortage of essential EmOC drugs, supplies and equipment were noticed in all the facilities including in MCWCs that has a well-established system of supply and repair. Shortage of Mag. Sulf, mucus suckers, ambu bags and endotracheal tubes were reported in many of the facilities. Readiness of instruments (sterile instruments packed in sets as per requirements of the procedure) is a concern. No clear directions on replenishment of the contents of SBA kits are available. Maintenance of equipment is another area of concern. The contraceptive logistics management system appears to be working efficiently. Recommendations
  • Drugs and supplies
    • A stock position of EmOC drugs and other emergency drugs should be available in the labour room and theatre. The responsibility for the same should be given to a staff member.
    • Regular laboratory supplies should be ensured in all the facilities that have a functioning laboratory (see also recommendations under section 3.7 'right to access to services'.
  • Instruments and equipments
    • Readiness of instruments for use should be ensured.
    • All the staff in the labour room should be trained in the use of neonatal resuscitation equipment and its care.
    • Consideration should be given for providing baby radiant warmers/heaters in labour rooms.
    • The system of maintenance of equipment should be strengthened / introduced in facilities where such a system does not exist
    • Equipment for MVA should be supplied to all EmoC facilities and staff should be trained in the procedure.
  • Mechanisms should be developed for replenishing the supplies of the SBA kit.
  • Logistics management system
    • The current efforts to strengthen the logistics management system should be extended to include EmOC drugs and supplies.
    • Storekeepers should be trained in the system.
    14. NGOs and private sector

    The main area of concern is the access of the poor to the services provided by the NGOs and private sector. The linkage between the public sector facilities and NGOs/ private sector is not clearly defined. This is critical for improving access to EmOC services. Recommendations
  • NGOs
    • A review of the current linkages between NGO institutions and Government Institutions should be undertaken with a view to identify potential areas of linkages in the delivery of safe motherhood, FP, RTI/STI services. Once the areas are identified, formal referral linkages should be established including mechanisms for reimbursement of cost of hospital care.
    • Monitoring the use of services by the poor under the UPHCP should be introduced.
  • Private sector
    • Private sector institutions should be identified for collaboration based on specific selection criteria. Linkages with such institutions should be formalised including mechanisms for reimbursement of cost of hospital care.
    • The private sector institutions should be oriented to national standards and guidelines and mechanisms should be developed to monitor the quality of care provided.
    15. Maternal mortality data

    The current HMIS or maternal death reviews do not provide complete information for monitoring maternal mortality as planned under the HNPSP.

    Recommendations
  • As recommended under section 3.3, maternal death reviews should be improved and a system of verbal autopsy should be introduced for completeness and accuracy of recording of maternal deaths.
  • Perinatal death audits should be introduced.

    WHO's publication " Beyond the numbers - Review of Maternal Deaths and Complications to Make Pregnancy Safer" is a very useful publication.

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