There is nothing quite like a birth, no matter where in the world you are.

Last month, I had the privilege to observe several mothers bring new life into the world in health facilities in northern Karnataka, India, where IntraHealth International is working with Karnataka Health Promotion Trust and other partners to improve maternal and newborn services in eight disadvantaged districts in the northern part of the state.

These visits to health facilities are always filled with highs and lows.

Larger systemic barriers remain.

On the one hand, I am elated to see how much the facilities’ health workers have accomplished with the skillful and sensitive support of nurse mentors hired and trained through the Sukshema Project to build the staff members’ skills. Compared to before the mentoring program began:

• The labor rooms are now well stocked with equipment and drugs.
• Broken radiant warmers have been repaired.
• Emergency drug kits are assembled and labeled so nurses can quickly manage postpartum hemorrhage or pre-eclampsia.
• Chlorine solution is prepared and ready for use, a standard recommendation that was rarely put into practice here before the mentoring intervention.
• Protocols for managing complications are posted on the labor rooms’ walls and nurses are using the case sheets we developed to guide them in assessment, diagnosis, and management.

The nurses tell me they are more competent and confident now, and it shows. I saw them provide active management of third stage labor, adhere to infection-prevention protocols, dry and wrap babies, administer newborn vaccines and vitamin K, and help mothers breastfeed their infants within 30 minutes of birth.

There is no easy fix for the problem of inadequate staff.

On the other hand, larger systemic barriers remain.

• None of the facilities—known as first referral units, to which lower-level primary health centers are expected to refer maternal and newborn complications—had anything close to the full complement of staff sanctioned for this level of care. (All first referral units should to have a 24/7 obstetrician, pediatrician, and anesthetist, in addition to nursing, lab, and pharmacy staff.)
• One facility that was managing up to 300 deliveries a month had only one part-time obstetrician and anesthetist on staff. Despite being a first referral unit that is expected to provide comprehensive emergency obstetric and newborn care, cases—especially for obstructed labor—had to be referred away to medical colleges or private hospitals.
• In another facility, a newly hired obstetrician fresh out of her training was seeing over 100 clients a day while also attending complicated deliveries, conducting a couple of C-sections and D and Cs each day, and supporting the labor room nurses in normal deliveries. There was no pediatrician at this facility. The day I visited, there were six normal deliveries and two C-sections, all handled by two nurses and two labor room attendants.
• Evidence points to the importance of monitoring women for 48 hours post-delivery, but it is a challenge for these few nurses to do so consistently.

There is no easy fix for the problem of inadequate staff.

It is hard to recruit specialists to these rural areas for all the usual reasons—lack of accommodation, inadequate infrastructure, low compensation.But there are other problems too—political interference, the potential for a community to turn on a provider if something goes wrong, and the lure of private practice, to name only a few.

At IntraHealth, we believe that every person deserves access to health workers.

These are challenging barriers, but we must understand and appreciate them in order to address health worker shortages.

Mentoring works

In northern Karnataka, the nurse mentors deployed by this project have helped ameliorate some of these staffing challenges.

The mentors work with nursing and other staff to:

• Build their skills in safe delivery
• Manage maternal and newborn complications
• Facilitate team-based quality improvement efforts to address gaps in equipment, supplies, infection prevention, and referral systems

While the program has been going on for a few years with primary health centers, it has now expanded to first referral units like the ones I visited. There, teams of two nurse mentors visit for six days a month. An obstetrician/gynecologist and pediatrician also each visit the facility for one day out of the six to conduct emergency drills with staff to sharpen their readiness to deal with maternal and newborn complications.

At IntraHealth, we believe that every person deserves access to health workers who are present where they are needed most, ready with the skills to deliver high-quality care, connected to information networks that support high performance, and safe to deliver services in environments that promote dignity and equality.

After 10 days in northern Karnataka, I couldn’t agree more.

The Sukshema Project is funded by the Bill & Melinda Gates Foundation. Partners include IntraHealth International, St. John's Medical College, Karuna Trust, and the University of Manitoba. Photos courtesy of Beth Fischer.