Competence of birth attendants at providing emergency obstetric care under India's JSY conditional cash transfer program for institutional delivery: an assessment using case vignettes in Madhya Pradesh province

Abstract

Background: Access to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. During implementation of the JSY, India witnessed a steep increase in the proportion of institutional deliveries-from 40% in 2004 to 73% in 2012. However, maternal mortality reduction follows a secular trend. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and therefore to a successful program outcome. We investigate, using clinical vignettes, whether birth attendants at institutions under the program are competent at providing appropriate care for obstetric complications.

Methods: A facility based cross-sectional study was conducted in three districts of Madhya Pradesh (MP) province. Written case vignettes for two obstetric complications, hemorrhage and eclampsia, were administered to 233 birth attendant nurses at 73 JSY facilities. Their competence at (a) initial assessment, (b) diagnosis, and (c) making decisions on appropriate first-line care for these complications was scored.

Results: The mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting >30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care.

Conclusions: Birth attendants in the JSY facilities have low competence at EmOC provision. Hence, births in the JSY program cannot be considered to have access to competent EmOC. Urgent efforts are required to effectively increase the competence of birth attendants at managing obstetric complications in order to translate large gains in coverage of institutional delivery services under JSY into reductions in maternal mortality in Madhya Pradesh, India.

Figure 1

Framework for clinical assessment by Miller [19].

Figure 2

Competence scores (maximum score = 20).

Figure 3

Histogram showing distribution of scores for Haemorrhage (3a) and for Eclampsia (3b); (maximum score = 10).

Figure 4

Proportion of competent respondents domain wise and by complication type.