Collaborative Action in Lowering Maternity Encountered Deaths

Background demographics

Although the life-time risk of maternal death dropped from 1:38 in 1990 to 1:170 in 2010 in India, it is still huge compared to the UK where the risk in 2010 was 1:4600 (World Health Organization (WHO), 2014). Within India, maternal mortality rates vary widely in different areas. Jawhar has been identified as having one of the highest rates: 150–300 deaths of 2000 women a year (Basu, 2012). Jawhar covers a rural population of 0.5 million and health care is provided by 11 primary health centres and one district health subcentre. In India in 2010, UNICEF identified that 47% of women had an institutional birth and 53% had their births assisted by a skilled birth attendant in the community. UNICEF also highlighted that as many as 49% of pregnant women did not have three antenatal visits during pregnancy and only 46.6% of mothers received iron and folic acid for at least 100 days during pregnancy (UNICEF, 2014). Before the authors visit in March 2013, personal communication identified that in the year 2012/2013 the maternal death rate had improved to 1:750—four women in 3000 died. Of these women, one was registered and three were unregistered. Two women died from septicaemia, one from postpartum haemorrhage and one from infective hepatitis. This followed the set-up of anaemia camps in the area and an increase in the rate of institutional delivery in Jawhar to 90%. After our visit, it was reported that there were no maternal deaths from March to December 2013 in the area (email communication Rotary District 1130, 2014).

Preparation

The VTT consisted of five members. There were two midwives who both had experience as advance life support in obstetrics (ALSO) instructors and teaching of skills and drills in their workplaces, a consultant paediatrician from the UK, an obstetric registrar who was based in Mumbai and a Rotarian from London to co-ordinate the venture.

Before leaving for Mumbai, meetings between the team members were organised via Skype and 6 contact days. In this preparation time, 10 modules (Box 1) were adapted and updated from material originally produced by the Liverpool School of Tropical Medicine, as due to copyright issues, original material could not be used. A 3-day teaching programme was put together, including teaching plans, which were rehearsed and confirmed by all members, and manikins were ordered.

Modules used for teaching

The VTT programme

The teaching programme was based on the ‘train the trainer’ model, which involves training ‘master trainers’ to train frontline workers. The training has specific goals of improving the master trainers' capability, capacity, productivity, and performance relating to specific areas of practice. The individuals will already know their subject matter but would need to add the skills and techniques to help pass that knowledge on to others (Rotary Today, 2013).

In order to enhance ‘train the trainer’ skills the team put particular focus on:

Training was delivered using a variety of teaching techniques including structured lectures with PowerPoint slides for facts and figures, small group activities, role-play using manikins and mnemonics for skills and drills, shared personal experience as well as quizzes and case discussions. The use of a wide range of methods encourages effective learning by keeping the interest active (Knowles, 1984).

The team had structured teaching plans for each module using methods as discussed, but needed to be able to adapt them once they got to know their audience, responding to the differing needs and learning styles of the students and acknowledging their aptitude and enthusiasm. Collaboration allowed the students to actively participate in the learning process. It gave them the opportunity to talk to each other and listen to other points of view. It enabled them to relate to the topic, and encouraged them to think in a less personally biased way. Collaboration methods can also allow teachers to assess the student's capacity to work as a team, take a leadership role, and utilise their abilities to present effectively (Tinzmann et al, 1990).

It is important to remember that for:

Week 1—Mumbai

Upon arrival to Mumbai, the Rotary and VTT jointly held a strategy meeting to review and confirm the training programme. The venue for the week was a conference room in a hotel in Thane, Mumbai. It was important to ensure the venue was able to support the learning and teaching environment.

The team of master trainers were already selected and included 13 obstetricians and gynaecologists with varying levels of experience ranging from novice to expert. One was just finishing medical school, and one was retired. There were no nurse/midwives. The structure of the programme was for the VTT to train the master trainers in week one over 3 days, then for the master trainers to deliver the programme in week two to targeted teams in Jawhar. These included local medical officers, nurse/midwives and ASHA workers (accredited social health activists or community health workers).

An inauguration ceremony preceded the programme and the modules were presented using methods as described earlier. The use of manikins was a new concept to many of the doctors who said they were looking forward to learning how to use them. Unfortunately the manikins didn't arrive until the end of the second day, so the order of the programme was rearranged and the practical sessions were all held on the third day. However, there was plenty of opportunity for the doctors to have hands-on practice and to support each other before preparing to deliver effective training in the Jawhar area the following week.

The receiving of feedback is known to enhance development and learning and this can encompass informal as well as formal processes (Box 2).

Good feedback practice

Informal feedback was given to the trainers during the practice sessions with the manikins, but the VTT identified that recommendations for the future would incorporate a more formal feedback method, to enable active participation and encourage positive motivational beliefs and self-esteem.

Feedback was also received from the trainers to the VTT after the first week. It was very positive, but by the end of the three days the programme organisers decided that the training material would be compressed into one day due to manpower and resources available. The plan for the following week was that 3–4 master trainers would travel to Jawhar on each of the 3 days to deliver one-day training to different groups of front line workers.

Training success can be measured by:

Ultimately, the VTT's goal in the ‘train the trainer’ course was to train the trainer to understand the importance of clear key messages and to be able to deliver those messages with sufficient confidence and flexibility that the student walks away with a precise understanding of what they need to do next.

At the end of the week, the VTT was invited to present a seminar on Saving Mother's Lives (Confidential Enquiry into Maternal and Child Health (CEMACH), 2011) and to demonstrate use of the manikins at the Nair Hospital Medical School, a public medical college attached to a large tertiary level teaching hospital. About 50 post graduate gynaecology and paediatric students attended. The team effectively delivered a baby with shoulder dystocia, resuscitated the baby and then managed a postpartum haemorrhage (PPH), with the aid of a manikin and a prepared box with emergency drugs.

It is well known that demonstrations help to raise student interest and reinforce memory retention because they provide connections between facts and real-world applications of those facts (Rotary, 2013).

It was noted that there are not many babies born in India with shoulder dystocia, but the demonstration was welcomed and the idea of keeping a PPH and eclampsia box ready in the ward was appreciated.

Week 2—Jawhar

The second week was based in Jawhar. On arrival in Jawhar the equipment and manikins were unpacked and set up for the next 3 days of training. Two of the master trainers administered the programme (Box 3) and looked after the VTT. Different master trainers and groups of trainees attended each day. The trainers all spoke Marati which was the main language spoken in Jawhar. The role of the VTT was to observe and support the teaching skills when required, not to teach; therefore the language spoken was not a barrier.

The master trainer programme

Day 1: 16 medical officers who worked in the local Primary Health Centre's attended. The modules were compacted together and practical skills were taught using the manikins. Feedback from the day was good, however, it was suggested that it should have been spread over 2–3 days. The skills learned using the manikins was highlighted very positively.

Day 2: 25 ASHA workers (Accredited Social Health Activists or community health workers) were expected to attend; however, 76 arrived. The training was initially through discussion, livened up by one trainer's supply of 10 rupee notes! Later resuscitation skills were demonstrated and there was good participation. The written feedback was positive and two ASHA women said that this was their first hands-on practice, and they would remember it forever.

Day 3: 25 auxiliary nurse/midwives (ANMs), general nurse/midwives (GNMs) and sisters were expected; however, 64 arrived, including the matron from Jawhar Hospital. Again, the day was divided into discussions in the morning and practical skills in the afternoon. The nurse/midwives were more nervous than the ASHA workers were initially, but they had a good interactive session and the feedback was positive although more hands-on skills experience were requested.

During the visit, the VTT were invited to see Jawhar Cottage Hospital where the local master trainers and some of the doctors and nurse/midwives who attended the course worked. It is a 100 bed sub-district hospital where primary health centres and community hospitals refer to if there are problems. ASHAs can also refer direct if they need to. The hospital was in the process of expanding to 200 beds. In the maternity area, the ante/postnatal ward was full. The labour room had one woman in it, although three beds and a ‘septic’ room were available. The operating theatre also had capacity for three beds. Emergency boxes had been made up for PPH and eclampsia as identified in the teaching modules.

On the final day there was a wrap-up meeting in Mumbai with the Rotary team and three master trainers to evaluate what had been achieved, to review the feedback and to discuss the way forward for CALMED. The VTT were asked to provide a SWOT analysis to evaluate the programme (Box 4).

SWOT analysis by vocational training team

Strengths identified:

Weaknesses identified:

Opportunities identified:

Threats identified:

Recommendations for the future

The VTT made recommendations that the master trainers should form a sub-committee to take charge of the training programme and to:

Maintain skills of those trained

The VTT shared the multidisciplinary working concept with the master trainers and advised them to consider general nurse/midwives to be trained as master trainers. As sessions develop, a system of talent spotting could be used to identify further master trainers. It is recognised that training from a multidisciplinary team can enhance the participation and results.

The immense research opportunities of this unique programme using data collected as above should be considered to be taken up and published.