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Vriddhi’s systematic capacity building initiative has improved the skills and con� dence of labor room sta� , empowering them to make improvements at work. It has equipped them to consciously work towards improved health outcomes by providing quality health care to mothers and newborns.

Empowering Health Workers

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Empowering health workers is essentially a systematic process aimed at improving individual competence and self-esteem, and

enhancing perceptions of personal control. This in turn helps health workers to take charge of their roles and work environment and motivates them to work to their full potential, to lead and sustain positive change.

Identifying sta� competencies as a core barrier to implementation of quality, high impact interventions at scale, the project devised the Care around Birth (CaB) approach for capacity building with the aim to ensure that health workers are not only well-trained, but also motivated and supported to provide high quality services.

Complementing the capacity building e� orts, the CaB approach also worked towards creating an enabling environment that would support behavior change viz an end-to-end Labor Room Management Information System (LR MIS) that helped to improve recording at source, and enabled facility, district and state managers to engage in the labor room improvement process.

Care around Birth approach Multipronged capacity building process

Inputs

Outputs

Outcomes

Quality of care

for mothers and

newborns

Training on technical

intervention package

Experience sharing

platforms

Mentoring visitsCon� dent,

motivated,

respectful,

e� cient and

responsible

labor room sta�

Empowered

health workers

Increased

coverage of

practices

Improved

experience of

care

Ending

Preventable

Maternal and

Newborn Deaths

Empowering Health W

orkers

Impact

Quality Improvement

processes

Care around Birth (CaB)is an integrated approach to improve the quality of care in the intrapartum and immediate postpartum periods. Implemented in 141 facilities in 26 highpriority districts (HPDs)

across six states, it focuses on interventions for childbirth as well as for management of maternal and newborn complications. A core element of the CaB approach was to build capacities of labor room sta� and the facility as a whole to catalyze change for improved care of mothers and newborns.

“I was very proud to see that a complicated postpartum hemorrhage case was internally managed entirely by sta� nurses. Earlier they would refer these cases because they lacked con� dence. Due to Vriddhi’s Care around Birth trainings, our sta� nurses have become more capable.”

Dr. Arun KumarMedical O� cer Incharge, CHC, Kalwa, Jind, Haryana

3

Training methods included simulations, demonstrations, case studies, role plays and other participatory methods.

Choice of training methods was guided by the following: enables spontaneous

participation of all participants builds on participants’

experiences, views and beliefs encourages peer learning allows self-assessment of

knowledge and skills

Energizers used to enhance learning – quick fun activities in between sessions helped to relax participants, increase their energy levels and enthusiasm to enhance learning.

Time allocated for training sessions (%)

Training design balanced content, and pace of sessions allowed participants time to absorb and re� ect and maintained a learning ambience, with emphasis on stimulating and motivating participants.

Training content focused on delivery of high impact technical interventions to mothers and newborns during childbirth and to manage complications, giving clear guidance on process and protocols during practice.

Training followed the sequence of birth to promote seamless care for mother and newborn.

Simulation based drills were used to build competencies for managing complications.

Cross-cutting issues of Health Systems Strengthening, records, labor room organization and Respectful Maternity Care (RMC) were integrated in the training.

High quality facilitation and mentoring helped to assure training quality. The training delivery process

was designed to create facilitators and mentors who could ensure uniform

training delivery and program outputs across the six states

and 26 HPDs.

“The Vriddhi team has really helped me in facilitating provision of KMC. The team has taken multiple sessions on providing KMC and tying the KMC binder correctly for us.”

Dr. AmanpreetGynecologist, SDH Malerkotla

Sangrur, Punjab

“In the training, there was a very good activity. Everyone was asked to write a question they had on a particular topic on a card. These cards were then pasted on a board and trainers and participants addressed the questions one by one. As cards were anonymous, participants could freely ask whatever they wanted to know.”

ManiniAuxiliary Nurse Midwife (ANM)

District Hospital Saraikela-Kharsawan, Jharkhand

Concurrent measurement of learning helped to keep discussions focused on weaker areas/gaps and to deliver a need

based training

The non-threatening training environment allowed participants to openly

voice their concerns and challenges and discuss ways to overcome them.

“The Care around Birth training helped set many things in motion. When I visit facilities, checking registers and availability of supplies helps me track the progress in each facility and I also help labor room sta� resolve their doubts.”

Dr. SubodhDistrict Technical O� cer (DTO)

Haridwar, Uttarakhand

The training modelTrainings set the tone and kickstarted the capacity building process. Experiential trainings based on adult learning principles were designed to promote the delivery of quality, high impact practices to mothers and newborns in the period around birth. The focus of training was to address the gap between knowledge and practice and to help workers overcome barriers, both environmental – work place related and personal – their own hesitations and fears, in translating their knowledge to action. Trainings were always participant-centered, emphasizing continuous assessment and establishing learning needs, to retain a strong focus on facilitated learning.

*Monitoring Progress of Labor, Active Management of Third Stage of Labor, Essential Newborn Care, Newborn Resuscitation, Postnatal Monitoring of Mothers, Postnatal Monitoring of Newborns, Initial Management of PPH, Initial Management of Pre-Eclampsia, Kangaroo Mother Care (KMC), Feeding of Low Birth Weight (LBW) Babies, Management of Maternal Sepsis, Management of Newborn Sepsis, Use of Antenatal Corticosteroids for Preterm Labor and Prevention of Parent to Child Transmission

Practice session

Plenary discussions

Presentation

Measurement for learning

7% 7%

59%27%

44

Establishing a learning need Sessions always started with establishing a learning need by allowing participants to realize that there is a gap in knowledge or practice. This was done through structured questions and answers, writing cards, and demonstrating existing practices.

Building on existing knowledge Participants’ responses were valued and facilitators provided additional new information only after summing up the group’s inputs. This helped to build upon existing knowledge and further highlighted the learning need.

Facilitating learning is at the heart of the capacity building process, it is the common thread for all processes – training, mentoring and Quality Improvement (QI). The capacity building process promoted change at several levels - service providers were empowered to change their behaviors and practices to improve health outcomes for mothers and newborns. The training design incorporated this principle in several ways. A typical session plan followed the general pattern of:

Facilitating learning and change

“Earlier we were not so con� dent during delivery and could not handle PPH on our own. Although we knew about atonic and traumatic PPH, we used to run to the doctors. Now we are able to manage it on our own.”

Ganga NegiSta� Nurse, Regional Hospital

Reckong Peo, Kinnaur, Himachal Pradesh

2

At the workplace, participants were supported by onsite mentoring and handholding to translate their newly acquired knowledge and skills into practice.

Establishing a learning

need

Building on existing knowledge

Learning by observationDoing,

observing and critiquing

Sharing problems, challenges

and solutions

Performing the new

skill

1

Display of ideas from participants’ brainstorming session

Facilitator summing up learnings from a session

5

Doing, observing and critiquing All participants were given an opportunity to practice individually under supervision in small groups. In addition to the group and facilitator, all co-participants observed the practice keenly. This further added to the learning experience.

Sharing problems, challenges and solutions This step allowed participants to re� ect on what they had learned and visualize challenges and issues in implementing the new practice. Open discussion helped them to suggest potential solutions to each other. At this stage, problems related to larger systemic issues such as supplies, infrastructure etc. which were beyond the scope of the training were also listed but parked separately to be taken up with higher authorities later. This prepared participants to list and bring such issues to the notice of their seniors in facility QI meetings later on.

Performing the new skill At the training participants demonstrated their newly learned skills and made commitments to continue the practice

5

6

Learning by observation The correct practice was demonstrated by the facilitator. The participants observed the demonstration and were encouraged to note di� erences from their current practice.

3

4

“CaB training sessions were di� erent from others that we attended in the past. They taught us practically using mannequins and exercises. The drills made us realize how each step under CaB could make the di� erence between life and death.”

Alka PradhanSta� Nurse, District Hospital

Saraikela-Kharsawan, Jharkhand

Demonstration on handwashing Working in small groups

Participants sharing their experiences and challenges

Nurse weighing a newborn, applying training learnings at facilitiesCommitments on improvement by labor room nurses

6

QI meetings as refresher sessionsLabor room sta� in CHC, Jama block of Dumka district in Jharkhand � nd that their skills are improving with each QI meeting. Earlier nurses were unsure about using the partograph to monitor labor. Now after several rounds of discussion in QI meetings, sta� are con� dent to use partographs and � ll them out correctly too.

Mentoring to reinforce learning and nurture change

“The DTO conducts regular mentoring and handholding visits. This has helped refresh our memories and reinforced our learning. When she oversees procedures, she points out our mistakes and clari� es all our doubts.”

Renu Sta� Nurse, Maternity Home

Yamuna Vihar, North East Delhi

QI sustains the momentumThe momentum for change was sustained by introducing QI processes at facility level. Operationalization of facility QI process enabled facility teams to start addressing challenges as a group.

QI teams instituted at facilities took up facility-level unresolved issues, identi� ed bottlenecks, brainstormed to � nd viable solutions, � xed responsibilities and timelines and eventually accelerated change. QI teams have instilled a sense of empowerment among health workers. They now have a platform where they can discuss and resolve emerging issues in their workplace.

Facilities take over QI processAt Civil Hospital, Joginder Nagar (Mandi district, Himachal Pradesh), Dimple Thakur, sta� nurse has taken the lead and conducts QI meetings even when the DTO is not available. She is of the � rm opinion that continuing QI meetings would help improve the facility.

At CHC Barwala in Hisar district of Haryana, Dr. Paramjeet, Senior Medical O� cer has taken the lead in organizing QI meetings. According to him, many improvements in the facility are a result of regular discussion and follow up at QI meetings.

6

QI meeting, CHC Barwala, Hisar, Haryana

MOIC

Sta� Nurses

Obstetric drill practice in facility

Follow up visits to facilities were used for mentoring and providing handholding support to service providers, resolving doubts and facilitating practice to boost con� dence and convince workers that they could transform the situation by making small changes in their daily routines.

Drills and checklists were introduced to maintain high level of preparedness among sta� to handle maternal and newborn complications.

A series of job aids and notes were given to labor room sta� to remind them of actions and interventions.

The consistent focus on data helped establish constant engagement with sta� , which in turn boosted the change process initiated during training.

Sta� incorporate newly learned skills into regular practice Improved maintenance of records in the labor room Peer-to-peer learning opportunities created by highlighting good

practices

7

Dissemination of learning

“Overall, there has been a huge di� erence in the quality of care being o� ered to patients. Very consciously, we now treat clients with dignity and provide respectful care to them, their attendants and families. This goes beyond just ensuring physical and medical care of the client.”

Archana DeviANM, CHC, Laksar

Haridwar, Uttarakhand

According to Dr. Manjula, Deputy Civil Surgeon and Vriddhi Master Trainer in District Hospital Jind, Haryana, when facilities present their � ndings and experience at district-level meetings, an environment for cross-learning is created among sta� and between facilities.

Drills are a medium of internal cross-learning. Everyone gets an opportunity to observe and practice and newcomers learn on the job.

Sharing news and achievements on WhatsApp groups promotes peer learning and sets up healthy competition.

Change is evidentVriddhi’s approach to empower health workers has helped create an enabling environment to improve labor room practices. The results are not restricted to clinical case management but also resource management for improved outcomes. Training in tandem with mentoring and handholding visits to facilities has enhanced capacities and improved con� dence levels of sta� to manage cases that they were afraid to handle earlier. Sta� is also visibly more aware of their roles and responsibilities, and have become active contributors to the process of change to bring about large scale improvement.

“The good aspect of this project was skill enhancement. Skills have been enhanced and these will stay with us. Sta� who have been trained and posted at facilities will remain there and will train the new sta� .”

Dr. Desh Raj Sharma Former Chief Medical O� cer, Mandi, Himachal Pradesh

Regular experience sharing platform (ESP) meetings were held to share learnings and experiences by sta� from implementation of the CaB approach. Facility and labor room sta� from intervention facilities shared their experience from implementing the CaB approach, their ability to manage cases competently and how they

work as a team to solve problems at their facilities. These voices became advocates for change and spreading the learnings. Regular reviews and progress updates at state and district levels ignited interest in recreating processes and extending the gains experienced by CaB facilities to other facilities and districts.

Cross-learning to spread the lessons

Learnings from CaB approach

scaled up to

265 facilities and 41 non-HPDs

914 service providers trained in non-CaB facilities

Vriddhi : the promise and the potential USAID’s � agship project Vriddhi is a technical partner to the Government of India and six state governments of Delhi, Haryana, Himachal Pradesh, Jharkhand, Punjab, and Uttarakhand. With the mandate of scaling up high-impact RMNCH+A interventions, Vriddhi, at the national level supports Government of India to formulate evidence-based policies and guidelines to implement RMNCH+A interventions. The project also facilitates concurrent evaluation of the programs across the High Priority Districts of the country through the

National RMNCH+A Supportive Supervision system designed and implemented in collaboration with Government of India and RMNCH+A partners. Across the six focus states, and 26 HPDs therein, Vriddhi provides support in planning, training, implementation, and monitoring for e� ective coverage and quality of all RMNCH+A interventions. Reaching a population of 131 million in the six states, Vriddhi has designed multiple innovative approaches for implementation with learnings for contextual adaptation across the country.

Vriddhi’s capacity building approach focused on individuals as agents of change to enhance their participation in improving their work environment and provide quality health care to mothers and newborns even in underserved and hard-to-reach areas.

Care around Birth: Optimizing Quality of Care at birth

The “Care around Birth” approach, is central to the project Vriddhi - Scaling up Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Interventions. Guided by WHO’s “Quality of Care (QoC)” framework for maternal and newborn health and the national RMNCH+A strategy, it is premised around the e� ective implementation of evidence-based Technical Interventions during intrapartum and immediate postpartum period – the most critical time for maternal and newborn survival. A holistic approach “Care around Birth”, integrates technical interventions with Health Systems Strengthening e� orts, Quality Improvement techniques and Respectful Maternity Care practices to optimize QoC at and around the time of birth.

DISCLAIMER: This document is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents are the responsibility of IPE Global Limited and do not necessarily re� ect the views of USAID or the United States Government.

Published: May 2018

Photo Credit: Vriddhi

463,713 mothers reached 458,152 newborns reached

Jan 2016

Jan 2016

Dec 2017

Dec 2017

Care around Birth practices improvedKey trends

Mothers correctly monitored with partograph

32%

83%

Mothers received timely oxytocin

35%

93%

37%

85%

Women counseled on PPFP methods

53%

94%

Newborns received Vitamin K1 after birth

36%

88%

Delayed cord clamping in newborns

14%

94%

Newborns monitored for vitals within � rst hour

Outputs of the integrated training approach

1,446 service providers trained in 141 facilities in 26 HPDs of 6 states

Around 800 service providers involved in QI processes

More than 3,000 low dose, high frequency mentoring visits at intervention facilities

Competency of facility sta� Routine baby care after birth

Newborn resuscitation

7.3%

69.9%

5.0%

81.9%