Community Mid-Wives (CMW) Program
Status Report prepared by PRIME/IntraHealth
1.
Background
USAID, through its Innovations in Family Planning Service project, has supported state
Innovations in Family Planning Services Agency (SIFPSA) with technical assistance
from PRIME/IntraHealth to establish a new cadre of private providers at the community
level, the Community Mid-Wives (CMW) in 4 districts of Uttar Pradesh. In 2002, the pilot
CMW Program, wich was ultimately launched, proposed to train 240 CMWs in the 4
districts of Varanasi, Sitapur,Agra and Meerut. In each district, 60 candidates were
selected from one selected tehsil for the program. The candidates were selected based
on pre-set criteria: 18-35 year old female of the village, minimum education of 10th class
pass. With preference to grass root level workers such as CBD (community-based
development workers) of NGO programs supported by SIFPSA, Anganwadi workers and
trained dais with minimum of 12 months work experience.
In total, 239 CMW trainees enrolled for the course in February/ March 04 in all the four
districts. Profile of the trainees are; the average age was 27 years with the minimum and
maximum age ranging from 19 to 38 years, 88 percent were married, and 53 percent of
them were intermediate or 12th pass.
The aim of this new cadre of CMWs is primarily to increase access to safe delivery,
quality family planning and other reproductive and child health services to address the
unmet needs of the community. This cadre is envisioned as a means to improve, with a
private, skilled provider, the outreach of services the services provided by the
government community health worker, the Auxiliary Nurse Midwife (ANM)..
Goal:
To develop a new cadre of private sector health care providers to increase access to
quality family planning, reproductive and child health services n the community.
Objectives:
1. To meet the reproductive health needs of women in communities including safe
delivery and child survival services
2. To increase access to and improve quality family planning-RCH services through
trained community midwives in each of the 4 pilot districts specifically selected in
the project
3. To select and train 240 community Midwives over a period of 18 months from
selected 4 pilot districts to provide quality family planning and RCH services in their
residential or and surrounding areas
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USAID and SIFPSA have set the following indicators to monitor the progress and to
assess the effect of this program by August 31, 2004 extendible till September 30,2004:
1. 160 of the trained CMWs found to be performing to standard (PTS) in clinical skills
2. Each of the successfully passed out candidates are provided with one IUCD kit, one
CMW kit, basic equipments and furniture provided for setting up their clinic
3. Each of the 160 PTS candidates will be certified by state Nursing and Midwifery
Registration Council (SNMRC).
The program utilizes the Government of India’s approved BHW training syllabus (18
months) to ensure that CMWs will be certified into an approved health care cadre.
Against this syllabus PRIME/IntraHealth developed a skilled-based, participatory training
package. The state Nursing and Midwifery Registration Council (SNMRC) conducts
examination of the CMWs on the same pattern as mentioned in the government of
India’s approved syllabus for Basic Health Worker (BHW) training and will certify them
as qualified BHWs after their successful completion of the third semester examination.
As a basic health worker, once certified, she can work as a CMW. Then the CMWs will
establish their fee for service clinic and practice in their respective villages and SIFPSA
will support them to establish their clinics. CMW trainers, guided by SIFPSA, will follow
up with CMWs during the first three months after training. ANMs and MOICs will provide
supportive supervision to the CMWs during the first six months of their practice. The 18month training program was initiated in February 2003 and has been divided into 3
semesters of 6 months each. The first semester was completed in August 2003 and the
second semester completed in February 2004.
2.
Interventions
SIFPSA, working with USAID and PRIME, developed and managed the project from the
selection of the candidates to their certification and plans to help the CMW with their
establishment of equipped clinics by providing a basic RCH equipment kit. The GoUP
supported the strengthening of the training sites. The specific assistance provided
through USAID’s PRIME contract included:
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2.
Development of 18 month pre-service curricula for CMW training package for
Master trainers, Lead trainers and CMW trainers based on international
standards adapted to national norms and reviewed by national, international
experts and the technical advisory group.
Assessment of training institutions (ANM Training Centers and clinical practice
sites) conducted and strengthened in the 4 pilot districts.
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3.
A cadre of district and master trainers trained and mentored in their
implementation of TOTs and actual CMW training in midwifery, reproductive
health, family planning and other health issues.
Trained Master Trainers and mentored training of lead trainers
Mentoring of CMW training in the 4 pilot districts to ensure quality clinical
training based on adult learning principles and hands on training of skills.
Development of and orientation to a Training Management Information System
to monitor the progress of training at all training levels and strengthened
capacities of CMW Trainers (ANM/PHN Tutors ) in implementation of TMIS
Incorporation of a PLM activity to improve training curriculum and approaches
Conducted a study to develop a Business Plan for practicing CMWs and
revised the business model chapter of the curriculum based on this Business
Plan and modelled the training of this chapter for the Tutors in each of four
districts.
Planned End of Program stakeholders lesson learned workshop for
implementers, donors, key government officials interested in this program.
Results
A gender sensitive, skill-based 18 month pre-service curricula developed for CMW
trainees and training package for Master trainers, Lead trainers and CMW trainers using
the participatory approach including adult learning principles and performance learning
methodology based on international standards adapted to national norms and reviewed
by national, international experts and the technical advisory group. The curriculum has
been well received and has been recommended by the UP State Nursing Council for use
as the standard ANM curriculum for the state of UP. Additionally, SIFPSA has placed
this curriculum on their web site and have had requests for copies from various states in
India and from all over the world.
9 Trained Master trainers (Lady Medical officers) covering training methodology,
supportive supervision, community diagnosis and key clinical areas such as focused
ANC, safe delivery, PAC, Adolescent Health, Selected Gynaecological Problems, Family
Planning and IMCI.
51 trained Lead Trainers (Lady Medical Officers, Medical Officers In-Charge) covering
training methodology, supportive supervision, community diagnosis and key clinical
areas such as focused ANC, safe delivery, PAC, adolescent Health, selected
gynaecological problems, family planning and IMCI.
18 trained CMW Trainers (ANM/PHN Tutors) covering training methodology, supportive
supervision, community diagnosis and key clinical areas such as focused ANC, safe
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delivery, PAC, adolescent health, selected gynaecological problems, family planning and
IMCI and clinical skills of midwifery, infection prevention, prevention, immunization, IMCI,
common gynaecological problems, FP counselling and services, screening for RTI/STIs,
first aid, basic nursing care, identifications of cases of tuberculosis, leprosy and malaria,
and field practice in community health.
4 strengthened ANM Training Centers (ANMTC) to improve the quality of 18-months
residential CMW training.
Linkages established between ANMTC and District Women’s Hospitals for clinical
practice of ANMTC trainers and CMW trainees
Upon graduation, Uttar Pradesh’s CMWs will be the first cadre of community midwives
ever developed in India. Other donor and the central government have worked to
develop this cadre in other states but to date none of these planned programs have
been initiated. The End of Program workshop will showcase this accomplishment.
The sections below present performance results of CMWs on the following skill and
content areas: Communication, Maternal Health, Reproductive Health and Family
Planning, New born and Child health, First Aid and Community Health till second
semester course that completed in February 04.
Continuation of trainees in first and semester courses
Of the 239 trainees selected and enrolled at the beginning of the training in
February/March 03, 97 percent continued until middle of the first semester in June 03,
90 percent until the end of the first semester in August 03, and 90 percent of till the end
of the second semester in February 04.
Performance of trainees in clinical skills practice during the training
During the training, in addition to classroom sessions, the trainees gain clinical skills
through practical sessions in the classroom on models, through role plays and in the
clinic with clients. Trainers used skill checklists for specific topics to assess the skills
while trainees practised. A trainee is declared performing to standard (PTS) if she scores
80 percent or more and performs all critical steps as per standards in a given checklist.
In first semester, three skills of antenatal history taking, haemoglobin and urine tests
were assessed. Overall, in first semester, 11 percent of trainees were PTS at least once
in antenatal history taking skills, 34 percent in haemoglobin test skills and 57 percent in
urine test skills. In total, 8 percent of the trainees were found PTS at least once in all the
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three skills they practised. As ANM tutors (the trainers) did not initially correctly apply the
checklists and the scoring guidelines, they made a lot of errors in scoring and also left lot
of checklist parameters not scored. Hence, many trainees who actually performed to
standard did not certify as PTS in the assessment in first semester. This fact needs to be
kept in mind while interpreting the data for the first semester.
In second semester after IntraHealth reoriented trainers to use of checklists, thirteen
skills were assessed. Overall, in second semester, 61percent of trainees were PTS at
least once in abdominal examination skills, 90 percent in labor (general examination), 83
percent in labor (history), 46 percent in vaginal examination, 41 percent in birth
assistance, none in IUCD counselling and clinical (insertion) skills, 90 percent in
newborn examination (< 12 hours), 88 percent in newborn examination (> 12 hours), 50
percent in counting breathing rate of infant 7 days to 2 months, 96 percent in care of the
newborn at birth, 75 percent in newborn resuscitation using bag and mask skill, all in
newborn resuscitation skill and 98 percent in RTI/STI examination skills. In total, 42
percent of the trainees were found PTS at least once in all the skills they practised.
Performance of CMW trainees in semester examinations
The State Nursing and Midwifery Registration Council (SNMRC) conducted the first and
second semester examinations of the CMW trainees in August 2003 and February 2004
respectively. To ensure fair conduct of semester examination, external examiners from
SNMRC and observers from IntraHealth supervised and invigilated the examination
process. A trainee is declared successful in the examination, of she scores 50 percent or
more marks in theory as well as in clinical skill practice.
Of the 216 trainees who completed the 1st semester course 202 (93 per cent) were
eligible and appeared in the 1st semester examination. Of those who appeared in the
examination,83 percent successfully qualified in the examination. On average, the
trainees who could not appear or could not successfully qualify the semester
examination were given two more chances to appear in the repeat examinations. In total,
of the 213 trainees who appeared in the 1st semester main or two repeat examinations
all of them passed.
Of the 214 trainees who completed the 2nd semester course, 190 (89 percent) were
eligible and appeared in the 2nd semester examination. Of those who appeared in the 2nd
semester examination, 99 percent successfully qualified. On average, the trainees
scored 65 percent in theory examination and 67 percent in the clinical skill test.
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4.
Lessons Learned
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Involving the State Nursing Council, Directorate Family Welfare and state Institute
of Health and Family Welfare officials responsible for the Basic Health Worker
(BHW) training, in the preparation of the curriculum for the private CMW trainees
from the beginning of the planning of this program lead to a successful outcome of
the UP State Nursing Council recommending use of the 18 month CMW curriculum
as the standard ANM curriculum for the state of UP.ANM Tutors from other districts
have begun asking for this curriculum for the newly initiated BHW training in UP.
Selection criteria and selection process for CMW candidates for training needs to
be reviewed in light of pilot experience to assure candidates selected are more
likely to remain in their village and not take new abilities to urban areas.
CMW trainers both LMOs and ANM Tutors are not, after the currently provided
TOTs, competent in the training methodology nor in the clinical skills they are to
teach and either need constant mentoring or a more extensive training preparation
(TOT).
ANM Tutors are the only trainers in the group of trainers for this program who are
nit additionally compensated for this training. While this is a sensible decision as
they are the only trainers who are not employed as clinicians but instead as
trainers, the result has been very un-motivated day to day trainers who complain
excessively of their lack of additional compensation. This attitude has affected the
quality of the training and needs to be addressed.
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While the following issues are not lessons learned from the implementation of the CMW
program, they are concerns gleaned from experience in introducing other new cadres
world wide.
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Re- certification of the trained CMWs every two to 3 years, to ensure on going
quality of services should be put in place, which at present has not been
included
Assist practitioners in on the job problems, a professional members association
for this cadre needs to be established as planned in a sister state which is also
initiating this program
These issues will be addressed in the End of program Workshop and may inform the
planned second round of CMW training in additional districts.
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