Bihar: Comprehensive Emergency Obstetrics and Neonatal Care
(CEmONC)
A project by Doctors-For-You for CARE-India
Background:
Bihar is a state in northern India. It is the 12th largest state in terms of
geographical size at 38,202 sq mi (98,940 km2) and 3rd largest by population.
Ancient Bihar was a centre of power, learning and culture in ancient and classical
India. Since the late 1970s, Bihar lagged behind other Indian states in social and
economic development terms and remains a state with the poorest health
indicators. Nearly 85% of Bihar's population lives in rural areas. Almost 58% of
Biharis are below 25 years age, which is the highest in India. The sex ratio is 919
females per 1000 males. Bihar statistics: MMR=305 NMR=32, IMR:55, <5=77,
Underweight=56%, Fertility rate=3.7
Partnership:
In a move to bolster Bihar's public health standards, the State government signed
a Memorandum of Cooperation (MoC) with the Bill and Melinda Gates
Foundation, in May 2010. Microsoft Chairman Bill Gates, who visited Bihar
signed the Ananya agreement in the presence of Chief Minister Nitish Kumar
with the objective of accelerating State-wide improvements in maternal, newborn
and child health for a five-year duration, from 2010 to 2015.
One of the partners of the Gates foundation is CARE-India, and under the
Integrated family health initiative (IFHI) – Ananya, has been building capacity
among nurses and frontline workers, upgrading facilities at primary centres, first
referral units, and at the District hospital.
http://www.ananya.org.in/ http://www.careindia.org/
http://doctorsforyou.org/
CARE works in close partnership with the Government of Bihar (GOB) under the
overall framework for the National Rural Health Mission (NRHM
, to provide
catalytic and facilitative support at sub-district, district and state level
. CARE
conceives, implements and tests novel solutions in a set of eight focus districts to
inform statewide implementation (some efforts go state wide) and helps the GOB
identify and transfer successful solutions statewide in an ongoing, concurrent
manner
. They support the GOB to document and disseminate proven
approaches to inform the national program
and coordinate and collaborate
across work streams internally, with development partners, Government of India,
and grantees.
Doctors-For-You (doctorsforyou.org) is the implementing agency contracted by
CARE-India for providing training for Integrated Management for Emergency
Obstetric Surgical Care: Tools and Technologies for Strengthening Doctors’
Skills (and Building Health System-Capacity) to Reduce Maternal and Child
Mortality in eight targeted, Priority District-Level Health Facilities in Bihar.
Primary Deliverable: Increasing rate of Caesarian section under Spinal
Anaesthesia, for Mothers in remote & rural areas lacking access to life-saving
emergency obstetric surgical interventions for pregnancy-related conditions.
Point of delivery: District (Sadar) Hospitals
Education &Training Plan:
1. One Senior Obstetric and one senior Anaesthesia Trainer will conduct the
workshop using the adapted IMEESC training curriculum for emergency
obstetric surgical interventions.
2. A full time Obstetrician and full time Anaesthetist will be available to handhold and supervision / reinforce the learnings from the WHO Training
workshop, until the follow up refresher workshop.
Deployment and Rollout plan:
• Buddy pairs: 1 Anaesthetist 1 ObGyn
• Two levels: Expert visiting facilitator and full-time Hand-holder
• 4 pairs in 8 district hospital – rota based.
• Create and maintain teams of senior and junior across 8 districts and 8
months
• Ensure mobility across 8 districts
• Ensure feedback to the learnings
Initial workshop on best practices and skill building - 2 per districts for 2 batches
of 15 participants (1st Batch: Mon-Tue-Wed and 2nd Batch: Thu-Fri-Sat) –
Training calendar appended below.
Mentoring, hand holding & supportive supervision at health facilities - By full time
specialist in between initial and follow up workshop
Follow up refresher workshop: after 4 months: per district for 2 batches of 15
participants
We see an opportunity for volunteers from the UK register and from Canada to
participate in training, hand-holding and research documentation. There needs to
be a third buddy pair of overseas physicians or nurses, alongside the handholding buddy pair. With the language barrier, the overseas volunteers will need
to supplement the teaching program, the operative supervision and help in
documenting practices and suggest behavioral changes. The minimum time for
volunteering will be one month. Meals, accommodation and local travel will be
provided by DFY, but not international airfare. There will be continuous seamless
rota for the coming 3 months ready, prior to the deployment of the first buddy pair
(preferably Anaesthetist+Obstetrician±Paediatrician. Also, one team will orient
and hand over to the next arriving team.
Overall Aims:
1. Attempt to reduce MMR in 8 district s of Bihar, India, by improving health
practices by providing mentoring, hand holding & supportive supervision to
doctors at district & block level health facilities using low-cost, evidence-based
emergency obstetric surgical care and anesthesia interventions
2. Telemedicine and partnerships with local and/or international physicians and
experts for continuing education/training programs, primarily for caesarean
sections.
3. Integrate and implement quality and safety measures at points of care
Heads of deliverables: A replicable, scalable, low-tech model
1) Labour surveillance
2) Deliver
3) Post-natal care
4) CEmONC
5) Conduct of FP procedures
6) Infection Control
7) Biomedical Waste Management
Specific training deliverables:
• C-section under Spinal Anaethesia
• Maternal complications: haemorrhage, prolonged labour, eclampsia, etc
• Procedures: Blood transfusion, induction and augmentation of labour,
Episiotomy, Vacuum-assisted delivery, Forceps delivery, Breech delivery,
etc.
• Neonatal complication like Birth Asphyxia, preterm baby, pneumonia,
neonatal sepsis, - Sick New Born Care Unit.
• STSC/Kangaroo Mother Care – warmth, hygiene, and breast feeding,
clean cord care and managing sick baby.
• Postpartum IUD insertion, mini-lap and tubectomy using standardized
protocols
• Infection Control acitivities, handwashing, protective equipment,
biomedical waste, sterilization etc
• Labour surveillance including WHO simplified partogram
• Active management of third stage of labour (with Oxytocin and
Misoprostol)
• Post partum counselling and evaluation of mother and new born
• Pre and post procedure care
• Medical Records (RTS, CARE)
• Proper referral linkages to other Public Health facilities
Intervention District Map
Timeline and Training Calendar for Districts
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BASELINE MEETING
JAN 30-31 2014
PATNA
GOPALGANJ
Break for HOLI festival
Mar
2014
SAMASTIPUR
MOTIHARI
BETTIAH
KHAGARIA
SAHARSA
PATNA
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BEGUSARAI
GOPALGANJ
SAMASTIPUR
MOTIHARI
MIDLINE MEETING
REVIEW
End of Project
Jun
2014
9th November 2014