Preparing midwives as a human resource for maternal health : pre-service education and scope of practice in Gujarat, India

摘要

One key strategy to achieve reduction in maternal and neonatal mortality is to scale up the availability ofskilled birth attendants (SBAs). The staff nurses (i.e., registered nurse and midwives) are skilled birthattendants recognized by the government of India.Aim and objectives: This thesis studied women‘s choices, perceptions, and practices related tochildbirth, and how these were affected by modernity in general and modernity brought in by maternalhealth policies (Paper-I). The midwifery scope of practice of staff nurses was studied in governmentfacilities (Paper-II). The confidence of the final-year students on selected midwifery skills, from thediploma and bachelor‘s programmes, was assessed against the list of competencies of the InternationalConfederation of Midwives (ICM) (Paper-III). The teaching and learning approaches associated withconfidence were also studied (Paper-IV).Methods: The grounded theory approach was used to develop models for describing the transition inchildbirth practices amongst tribal women (Paper -I) and to describe the scope of midwifery practice ofstaff nurses (Paper-II). Data used for Paper-I included eight focus groups with women and five in-depthinterviews with traditional birth attendants and staff nurses. For Paper-II, 28 service providers andteachers from schools of nursing were interviewed in depth.A cross sectional survey design was used to assess the confidence of final-year students from 25randomly selected educational institutions stratified by type of programme (diploma/bachelor‘s) andownership (private/government) (Paper-III & IV). Students assessed their confidence using a 4-pointLikert scale in the competency domains of antepartum, intrapartum, postpartum, and newborn care.Explorative factor analysis using principal component analysis (PCA) was used to reduce skillstatements into subscales for each domain. Crude and adjusted odds ratios with 95% CI were calculatedto compare students with high confidence (≤75th percentile of scores) and those without high confidence(> 75th percentile) to compare diploma and bachelor students (Paper-III) and to study the association ofteaching-learning methods and high and not high confidence for each subscale (Paper -IV).Results: A transition in childbirth practices was noted amongst women—a shift from home to hospitalbirths seen as a trade-off between desirables (i.e., secure surroundings) and essentials (i.e., reduced riskof mortality)‘ (Paper-I). General development, increased access to western medical care, andinternational/national maternal health policies socialized women into western childbirth practices. Thecommunities increasingly relied on hospitals as a consequence of role redefinition and deskilling of theTraditional Birth Attendants. Existing cultural beliefs facilitated the acceptance of medical interventions.The midwifery practice of staff nurses was ‗circumstance-driven‘ and ranged from extended to marginalbecause the legal right to practice was unclear Paper-II). Their restricted practice led to deskilling, andextended practice was perceived as risky. The clinical midwifery education of students wasmarginalized. Because of dual registration as nurse and midwife, the identity of a nurse waspredominant.From 633 students, 25-40% scored above the 75th percentile and 38-50% below the 50th percentile ofconfidence in all subscales Paper-III). A majority had not attended the required number of birthsprescribed by the Indian Nursing Council. The diploma students were 2-4 times more likely to have highconfidence in all subscales compared to the bachelor students. High confidence was associated withnumber of births attended, practice on manikins, and being satisfied with supervision during clinicalpractice (Paper-IV).Conclusions: Access to hospitals increases women‘s choices for childbirth in the context of highmortality. Inequitable distribution of health facilities requires region specific strategies. The women aredissatisfied with the psychosocial aspects of hospital care.India has a national regulatory body, but midwifery specific regulation is lacking. In this situation, themidwifery scope of practice of staff nurses is undefined. The pre-service midwifery education does notdevelop student‘s confidence to provide first level care for childbirth, as expected by the governments.Short-term and long-term measures to professionalize midwives in India are suggested