What comes to mind when you think of a nurse delivering babies in a rural public healthcare facility? Rude? Inefficient? Lazy? I thought so too. Over the last three years, I have seen a different side to them, especially SBAs.
First, who is an SBA? An SBA (Skilled Birth Attendant) is a nurse, specifically trained to manage pregnancy, child birth and postnatal care. She is also equipped to identify and manage complications in pregnant women and new-borns and makes referrals as required. One would assume that deliveries are typically conducted by doctors, assisted by nurses. Or nurses, supervised by doctors. In reality, in rural India, most deliveries are carried out by nurses. Unassisted. Often, there is little choice.
India's public health facilities are organised along three tiers from the bottom-up: Sub centres, Primary Health Centres and Community Health Centres. A sub-centre caters to a population of 5,000 and provides non-invasive services. A Primary Health Centre (PHC) serves a population of 20,000 - 30,000 and is typically the first point where a villager can consult a doctor and avail of her/his services. According to India's Rural Health Statistics (RHS) 2016, the government has sanctioned 34,068 doctor posts for PHCs. Of these doctor posts, 26% are vacant. Inadequate presence of doctors increases the nurse's burden.
The next rung, the Community Health Centre (CHC), serves a population of 80,000-120,000 and is better-equipped. It can handle caesarean sections and is required to have blood storage units. Each CHC is required to have one obstetrician / gynaecologist to manage deliveries. For its 5,510 CHCs, the government has sanctioned 3,005 obstetrician / gynaecologist posts. Of these, over 61% are vacant according to RHS 2016.
According to the National Health Family Surveys (3 and 4), the percentage of births in public and recognised private hospitals has increased from 38.7 per cent in 2005-06 to 78.9 per cent in 2015-16.The Janani Suraksha Yojana granting a cash incentive to pregnant women for delivering in public or accredited private facilities, was majorly responsible for this. It is one of the greatest Indian public health success stories.
Estimated births in public facilities have increased to 2.65 times from 2005-06 to 2015-16. While this is a welcome development, number of obstetricians / gynaecologists in CHCs have reduced: 1,338 in 2005 to 1,146 in 2016 as per the Rural Health Statistics. In the same period, nurses in position at PHCs and CHCs have increased from 28,930 to 65,039. Naturally, nurses are expected to 'step up'.
Radha* is a 32-year-old Skilled Birth Attendant (SBA) serving in a CHC in rural India. She receives three to four cases of Post-Partum Haemorrhage (PPH) each month. PPH refers to the loss of mother's blood in the first twenty-four hours after childbirth and is one of the leading causes of maternal mortality. Earlier, even when care was necessary, and Radha could have managed, she chose to refer them to a distant, higher facility as she lacked confidence. She was scared that she would be held liable.
Put yourself in the shoes of someone like Radha. You were trained at the age of nineteen in a district facility with 'ideal' resources and adequate manpower. You observed doctors deliver babies and learned how to 'assist' them. Now you are posted in a far-flung CHC. With minimal additional training as an SBA on themes such as post-partum care and essential new-born care, you are now expected to frequently and single-handedly manage three to four deliveries simultaneously. The facility doesn't have half the resources you were trained to use. You routinely work 14-hour days and can seldom afford to take time off since the facility is understaffed. There is practically no guidance from supervisors. When they visit, they pick faults and seldom appreciate your work. They pressurise you to submit 'good-looking' data and you feel compelled to fudge numbers. You receive guideline documents, but nobody explains them to you. Despite your efforts in these challenging conditions, you see children and mothers dying. You receive little to no support from the community you serve. They constantly question your ability and demand instant referrals. They hold you liable for complications and deaths. You feel helpless. They don't want to give you a chance. But you still carry on.
Amidst all these challenges, India's neonatal mortality per 1,000 live births reduced from 35.2 in 2005 to 25.4 in 2016. Credit goes to courageous SBAs in facilities across the country, who have battled all odds. The Antara foundation's nurse mentors work with SBAs like Radha in PHCs and CHCs with high case load. They act as friendly coaches, training mentees in-situ. Through theory sessions, workshops and hand-holding, they have raised the confidence of their mentees. Since the nurse mentoring intervention, Radha has used her improved knowledge to attempt primary management of post-partum haemorrhage. She ensures that critical equipment is available when and where required, in the labour room. Her ability to handle normal childbirth has also improved. She now feels empowered to prevent complications and is now able to save more lives.
Another relevant example is Dakshata, a strategic initiative launched by the Government of India to improve quality of care during and immediately after childbirth. Jhpiego, an international public health organisation affiliated with The John Hopkins University, is the lead technical partner. The initiative provides nurses with structured training, mentoring and in-facility support, in accordance with the World Health Organisation's Safe Compliance Checklist.
Across rural India, nurses are punching above their weight in extremely tough conditions. Yet, we dismiss them as inefficient, rude and arrogant. In my experience, I have learned that with respect, empathy and investment in their skills, the sky is the limit for these women. They are the unsung heroes of Indian healthcare. So, the next time you encounter a nurse in a distant public health facility, say thank you. That is the least they deserve.
*Name changed to protect identity
Piyush Mehra is the CEO, Antara Foundation. He has worked in management consulting with Arthur D Little and KPMG. Share your feedback at firstname.lastname@example.org. He tweets at @iamPiyushMehra