By Nipurnh Gupta
PATNA, India, 14 November 2012 - “Insert it slowly, from the nose, down to the stomach. Be careful or you may enter the lungs, Gudda is just a day old,” calls out the doctor. Gita Bharti’s, an Auxiliary Nurse Midwife (ANM), hands shake as she picks up the Naso-gastric tube (NGT) and bends over the new-born.
“From the nose to the stomach, from the nose to the stomach,” she murmurs, repeatedly to herself, as she starts measuring the correct NGT length to be inserted into the new-born. “Eighteen inches”, she marks, and then starts inserting, slowly, carefully, her hands still shaking.
“It is going the wrong way. Take it out immediately,” interjects her watchful supervisor. “Try again, like this,” she shows “slowly, carefully”.
Little Gudda looks on, quietly, patiently, as Gita and her five colleagues, all ANMs, take turns, inserting NGT and oro-gastric tube (OGT), through Gudda’s nose and mouth. This is the first time they have seen an NGT.
“I can do it,” gushes Gita, a few minutes later, her face beaming, hands steady – manoeuvring the NGT skill-fully now. “I can feed the sick new-born or do a gastric wash using NGT,” she says with a new confidence.
“Luckily for us, Gudda is a plastic doll, a dummy, and we can practise again and again, till we get it right,” explains Nisha, another ANM, as the group moves on to the next table, or `skill-station’ as they call it to learn and practise resuscitation using a mannequin. Later they learn using the photo-therapy machine to treat to another critically sick `gudda’.
Back at the health centres in the villages, there’s no time to think or fumble. Babies are real, they cry, gasp, and writhe in pain. Each second is crucial. Precision is the key.
Skilled hands, right procedure and right equipment can save new-borns and mothers. And, vice-versa, lack of skills can kill.
Fortunately, the state of Bihar-the third most populous state in India, and amongst key contributors to child and maternal deaths, realised this early.
Over the last few years, the State Government, with support from UNICEF, has focussed extensively on improving facility-based healthcare for new-borns and mothers with new-born care corners (NNBCs), special new born care units (SNCUs) and labour rooms in first referral units across the state.
A high priority has been on building hands-on skills of health care providers right from medical officers in state and district hospitals, down to staff nurses and auxilliary nurse midwives (ANMs) and community health workers (ASHAs). The results have been encouraging – more babies and mothers are surviving now.
The state’s Infant Mortality Rate (IMR) is down to 44 per 1,000 live births from 51 in 2010, and Maternal Mortality Rate (MMR) has reduced to 261 per 1,00,000 live births. There is much more to be done though, to meet the Millennium development goal targets of IMR 30 and MMR 100 respectively.
Learning by doing
“The`SkillsLab’ initiative is a capacity-building innovation piloted by Bihar Government with UNICEF support. Having skilled-up around 1130 health staff across the state in less than a year of starting up, the innovation is being considered for scaling-up at the state and national level by the department of health,” shares UNICEF Bihar Chief, Dr Yameen Mazumder.
Explaining the background, Dr Ravichandran Chandrasekaran, Health Specialist, UNICEF Bihar says, “At present, an average healthcare functionary is required to use several new gadgets and instruments to perform routine tasks related to ante-natal, natal and post-natal care. Many rural ANMs have never ever seen modern gadgets like digital blood-pressure machines, radiant warmers, photo-therapy units, let alone knowing how to use them correctly. This impacts on their performance and quality of healthcare to pregnant women and infants.”
`SkillsLab’ is a specially-designed `laboratory’ where participants build knowledge and skills through hands-on practice using simulated scenarios and real equipments. Bihar is the first state in the country to have introduced the `SkillsLab’ concept in the public health domain, especially in mother and child health care, informs Dr Ravichandran.
UNICEF helped the state health department to set up the first SkillsLab at Guru Gobind Singh ANM School in xxx, which trained up 20 medical officers as master-trainers. “Subsequently, the health department has set up two mobile SkillsLabs which cater to health functionaries from districts,” informs Dr Apurva, one of the mobile SkillsLab team-leaders.
“Each SkillsLab has 35 skill-stations -18 knowledge stations and 17 demonstration stations- related to practical knowhow on mother and child health,” explains Dr CMP Singh, another team-leader. Over three-days, in small groups of 4-5 people, participants are trained by a facilitator who assesses their knowledge and updates or clarifies what they already know. The facilitator then demonstrates the correct procedure on a `child or mummy dummy’, and then asks them to practise, till they pick-up the skills.
“On day one of the course, when I was assessed for using autoclave for sterilisation, I could answer only half the questions. But now I know all answers and can also use it correctly,” says an elated Rukmini, staff nurse undergoing the SkillsLab course at Benipur regional hospital, in Dharbhanga (North Bihar).
Doctors have also benefitted. “Before coming, we doubted whether we would learn anything new, having done our Bachelor Course in Medicine and Surgery (MBBS) and attended several other trainings,” confides Dr Kunal Kishore, Medical Officer, at Bhadurgarh primary health centre.
Building capacity and confidence
Participants feel much more empowered to do their job after the SkillsLabs. With little hands-on training provided to them during the 18-month Auxiliary Nurse Midwives course, they often end up using trial and error methods.
“So, it is really good that we are getting hands-on practice at the SkillsLab,” Gita says, as she moves to `child-birth skill-station’ to practise how to deliver a child, with a `Ma ka putla” (mummy-dummy), which is pretty much a limb-less torso of a woman in labour with a slit `which dilates’ and holds an umbilical cord inside.
Not only the SkillLabs are making a difference in the confidence of the midwives and doctors, but also in the skills of health functionaries. “They are now much more cautious of crucial steps, including the often-repeated but most neglected hand-washing and sterilisation techniques to prevent infections,” says Dr Mithilesh Jha, Medical Officer in Charge of Bahudurgarh Block PHC, who has sent 45 nurses and doctors to the course.
To assess the impact of the programme and measure and use of the skills, the Government of Bihar plans to do an evaluation. In the meantime, the state Government continues with its plan to set up SkillsLabs in all 25 nurse training schools in the state to institutionalise this skill-building initiative aimed at saving mothers and children in Bihar.