“You have to play a major role in . . . safe delivery,” says Sister Nirmala to her class of frontline health workers training to become skilled birth attendants in the state of Jharkhand in India. “Today the maternal mortality has been reduced to 254—still it’s high. Now we have to bring it further down. . .”

A master trainer who goes the extra mile

A nurse in Hazaribagh’s district hospital labor room, Sister Nirmala became a master trainer in skilled birth attendance in early 2010. That means Nirmala goes on to teach other health workers what she now knows: how to manage normal, uncomplicated pregnancies and deliveries and how to identify, manage, and refer any complications that arise.

Sister Nirmala’s enthusiasm for her work and her students is boundless. Staying up into the early morning hours after a full, 12-hour day in the hospital labor room, Nirmala tirelessly prepares for class: she draws images on flip charts to make information clearer, and she transforms the material to provoke dialogue and discussion, even though lecturing from the podium might be easier. Nirmala is reluctant to release her pupils until they fully understand the subject. “Until and unless you remember the four stages of labor,” she tells them, for example, “I am not going to move to the next session.” She coaches her trainees to practice conducting deliveries again and again, and she visits trainees after sessions in case anyone needs further explanation on a class topic.

IntraHealth contributes to an improved training program

India bears the world’s highest burden of maternal mortality in terms of its absolute numbers. Many rural, pregnant women historically have turned to birth attendants who might not have the medical knowledge to perform deliveries, often with dire consequences for both mother and child.

Sister Nirmala’s work is part of India’s National Rural Health Mission, which aims to make safe deliveries more common in rural areas. The Jharkhand State’s Rural Health Mission director asked the IntraHealth International-led Vistaar Project to support efforts to reduce maternal mortality in Jharkhand, a state with one of the highest maternal mortality ratios in India. In response, the USAID-funded Vistaar Project assisted in designing the state’s skilled birth attendance training program: strengthening the training of trainers and post-training follow-up—including supportive supervision—and improving the supply of essential drugs. The project worked with the Deoghar District’s skilled birth attendance training for health workers posted at primary health centers and at health subcenters—especially critical since workers there reach people who would otherwise not have access to immediate health care. More recently, the Vistaar Project began leading scale-up of the training in 13 other districts—including Hazaribagh District.

Model district shows promising results

Although the Hazaribagh District’s program is too new to have data, the Deoghar District’s skilled birth attendance training program has shown promising results and serves as a model for the other districts: the mean total of deliveries conducted by auxiliary nurse-midwives (now trained as skilled birth attendants) has increased to 4.2 per month (in June 2010) from 2.5 per month (at baseline, in November-December 2008)[1]. The initiation of breastfeeding within one hour of all deliveries has also increased from 58% (at baseline) to over 98% (June 2010).

The improvement in deliveries attended by skilled birth attendants would not have been possible without the dedication and unshakeable commitment of frontline workers like Sister Nirmala.

[1] The baseline was conducted in November-December 2008. N=69 (Nov-Dec 2008); N=140 (June 2010)