http://doi.org/10.33698/NRF0094 – Neerja Sharma, Indarjit Walia, Sushma Saini Kumari
Abstract : This descriptive study was conducted in Chandigarh city. A total of 502 Government and private health care facilities were visited to ascertain the availability of skilled birth attendants (SBAs). The study revealed that 2261 SBAs were available in the City but they were not evenly distributed. Major concentration has been found in Sectors 12, 16 and 32 where government health institutions were located and in Sector 34 where private hospitals were available. Majority of the SBAs were having GNM qualifications. There were some sectors where no SBAs were available. The ratio of SBA to population tremendously varied but was much better where major health institutions were located.
Key words :
Skilled Birth Attendants, Availability
Correspondence at :
Neerja Sharma
MSc Nursing Student,
National Institute of Nursing Education, Chandigarh
Introduction
Pregnancy is a normal healthy state which most women aspire to at some point of their lifetime. Proper antenatal care can ensure at the end of pregnancy, a healthy mother and a healthy baby. Mother and children survival makes the society prosper in which they live 1.
Bir th attendants, both trained and untrained, is known to have played a major role in prenatal, intranatal and postnatal periods. Midwifery training, practice and standard setting processes in India have also undergone many changes aiming at building an efficient and skilled cadre of bir th attendants since independence 2. Until the mid 90’s the term ‘trained’ attendant was commonly used and it included both professional and non-formally trained community based providers of care during pregnancy, child bir th and post natal period3. From 1996 onwards the term “skilled” attendant was employed, recognizing that someone who has been trained is not necessarily skilled. GOI considers the skilled bir th attendant as a person who can handle common and major obstetric and neonatal emergencies as well and recognizes when the situation reaches a point beyond his/her capability and refers the woman or the newborn to a First Referral Unit/ Doctor 4.
Skilled bir th attendants can make a difference between life and death for a mother and her newborn 5. They have also helped in providing the women with emotional and practical support assisting them to deliver healthy babies and promoting bir th as a positive experience. Evidence supports the fact that in less developed regions more than half pregnant women gave birth with the help of an unskilled person and thir ty five percent had no contact with the health care system during pregnancy 6.
Concerns about availability of SBA’s have been expressed that the strategies required are complex and too difficult to implement because of human resource constraints 7. A key constraint limiting progress is the gap between what is needed and what exists in terms of skills and geographical availability of human resources at local, national and international levels 8. Even where services are available they are often inadequate or of a poor quality 9.
Gross inequalities prevail in terms of number of births attended by SBA’s among developed (almost all deliveries), developing (59.1%) and least developed nations (34.3%)10. In India 48.2% birth were attended by SBAs in the year 200711 with an improvement in antenatal visits, institutional deliveries, consumption of Iron Folic Acid (IFA) tablets for 90 days and postnatal visit within two days by health care provider.
Every woman has the right to care from a skilled birth attendant during pregnancy, childbirth and immediately after birth. For this to happen the WHO estimates that the number of skilled attendants in the developing countries needs to be increased by at least 3,33,000 8. In a study conducted in Chandigarh Union Territory, 21% of deliveries in rural and 7% in urban areas were repor tedly not assisted by skilled birth attendants, with this percentage as high as 68% in slums 12.
In Chandigarh, Union Territory an estimated 25,000 deliveries take place annually 13. However, the availability of skilled bir th attendants in Chandigarh was not known. This study was conducted to ascer tain the availability of skilled bir th attendants by covering Chandigarh City.
Objective
The study was conducted to find out the availability of skilled bir th attendants (nursing personnel and health workers female) in the Chandigarh City.
Material and Methods
The study has been conducted in the Chandigarh city. It has a total area of 114 sq. kms. and a total population of 9,00,635 (5,06,938 males and 3,93,697 females) with birth rate of 21.45%. Chandigarh is unique because it is the capital of two states, Punjab and Haryana. Chandigarh ranks first in India in the Human development Index, quality of life and e-readiness 14. The birth rate and the infant mortality rates are lower than that of adjoining states. The City is exhibiting better profile of prosperity as compared to adjoining states as well as national level in spite of it being thickly populated 14.
The city has Post Graduate Institute of Medical Education and Research, General Multi-Specialty Hospital, Government Medical College & Hospital and one Hospital each in the field of Homeopathy & Ayurveda. Apart from these, there are various other private Hospitals and Clinics in the City. In addition, there are Government Dispensaries located in the City.
All health care providers at Government as well as private health facilities in the Chandigarh City were included in the study. Two performa were developed after review of literature and in consultation with experts from the field of nursing and preventive and social medicine. Content validity of the tool was also determined. Information about existing Government as well as private Health Care Facilities in Chandigarh was collected. The data was collected from September to December, 2008 by visiting all the Government and private health care facilities personally. In all 502 health care facilities were visited. Only 4 private health care facilities refused to provide the information. Data was analysed using descriptive and inferential statistics.
Results
A total of 2261 SBAs were available in Chandigarh City as shown in Table 1
Table 1 shows that a total of 2261 SBAs were available in Sectors 1 to 63. It was found that Sector 12, in which the Post Graduate Institute of Medical Education and Research is situated, had 1408 SBAs which were maximum as compared to other Sectors of the city. Sector 32 in which the Government Medical College and Hospital is situated had 405 SBAs and Sector 16 having Government Multi-specialty Hospital had 100 SBAs.
Sector 34 had 6 private hospitals, 1 civil dispensary, 1 nursing home and 6 private clinics and there were 105 SBAs in this Sector.
Table 1: Availability of SBAs in Sectors of Chandigarh City
| Sector No | No. of SBAs |
| 3 | 3 |
| 4 | 1 |
| 7 | 1 |
| 8 | 5 |
| 9 | 6 |
| 10 | 1 |
| 12 | 1408* |
| 14 | 4 |
| 15 | 6 |
| 16 | 100** |
| 17 | 17 |
| 18 | 13 |
| 19 | 19 |
| 20 | 12 |
| 21 | 21 |
| 22 | 20 |
| 23 | 2 |
| 24 | 2 |
| 25 | 5 |
| 26 | 8 |
| 27 | 1 |
| 28 | 6 |
| 29 | 7 |
| 30 | 1 |
| 32 | 405*** |
| Sector No | No. of SBAs |
| 33 | 132 |
| 34 | 105 |
| 35 | 9 |
| 36 | 4 |
| 37 | 2 |
| 38 | 8 |
| 40 | 3 |
| 41 | 3 |
| 42 | 4 |
| 43 | 6 |
| 45 | 7 |
| 46 | 23 |
| Total | 2261 |
Note: Sectors 1, 2, 5, 6, 11, 31, 39, 44 and 47 to 63 did not have any SBAs
*,**,*** – Major Health institutes of the city located in these sectors
In other Sectors in Chandigarh the number of SBAs was comparatively very small. Many of these Sectors did not have even a single SBA. Four sectors namely, Sector 12, Sector 16, Sector 32 and Sector 34 jointly had 2018 (about 89 per cent) of the total number of SBAs in Chandigarh. The remaining 58 Sectors had a total strength of 243 SBAs which was about 11 per cent of the total SBAs in different Sectors of the City. These findings depicted that the population residing in and around four Sectors namely Sectors 12, 16, 32 and 34 had easy access to avail the services of the SBAs. It is worth mentioning that Sectors 1, 2, 5, 6, 11, 31, 39, 44 and Sectors 47 to 63 did not have any SBA. The population staying in these Sectors had to approach other Sectors to avail the services of SBAs. Also the concentration of SBAs in the Sectors located in the heart of the city was more than that of Sectors located outer part of the City. Figure 1 also depicts the availability of SBAs.
The SBAs available at different health care facilities in Chandigarh City possessed different qualifications. Table 2 below depicts the distribution of SBAs in the Sector of Chandigarh City and their qualifications.
Out of a total of 2261 SBAs in Chandi- garh City, only 7(0.3 percent) possessed Ph.D. / M.Sc. qualifications. Majority of the SBAs numbering 1730 (76.5 per cent) had GNM qualification and 420 (18.6 per cent) were having B. Sc. Degree. The remaining 104 (4.6 per cent) were MPHW(F)/LHVs. It is clear that City had maximum number of SBAs with GNM qualification. SBAs with B.Sc. and above qualification were concentrated in a few Sectors of Chandigarh.
Table 2 : Distribution of Skilled Birth Attendants in Chandigarh City and their qualifications N = 2261
Qualification n (%)
Ph. D. /M. Sc. 7 (0.3)
Sc. 420 (18.6)
GNM 1730 (76.5)
MPHW(F)/LHV 104 (4.6)
Out of a total of 2261 SBAs in Chandigarh City, only 7(0.3 percent) possessed Ph.D./M. Sc. qualifications. Majority of the SBAs numbering 1730 (76.5 per cent) had GNM qualification and 420 (18.6 per cent) were having B. Sc. Degree. The remaining 104 (4.6 per cent) were MPHW(F)/LHVs. It is clear that City had maximum number of SBAs with GNM qualification. SBAs with B.Sc. and above qualification were concentrated in a few Sectors of Chandigarh.
The details of these Health Care Facilities where these SBAs were positioned have been shown in Table 3
- No. Type of Health Facility n
- No. Type of Health Facility n
- Homeo Clinics 49
- Ayurvedic Clinics 36
- Miscellaneous 16
Total – 502
Sector 22 had maximum number (33) of Health Care Facilities. There were 7 Sectors having only one Health Care Facility and Sectors 2, 5, 39 and Sectors 47 to 63 did not have any Health Care Facility.
Table 4 shows ratio of SBAs to population in different Sectors of Chandigarh. There were 20 sectors which do not have even a single SBA. The ratio was much better in Sector 12 (1:4), Sector 32 (1:28), Sector 17 (1:44), Sector 34 (1:48) and Sector 16 (1: 49). This was because of the presence of main Government and Private Hospitals in these Sectors. In contrast the ratio of SBAs to population was very poor in Sectors like Sector 27 (1: 12523), Sector 30 (1:11045) and Sector 7 (1:10934). Rest of the Sectors also had varying ratios of SBAs to population between 1:112 to 1: 8562. It was important to note that even thickly populated Sectors
- Government Hospitals 9
- Government Dispensaries 26
- Private Hospitals 23
- Private Clinics 203
- Private Nursing Homes 10
- Dental Clinics 98
- Lab/Diagnostic Centres 32
like Sector 51 with a population of 28764 and Sector 56 with a population of 24444 did not have even a single SBA. It was clear that there were huge gaps in ratio of SBAs and population in different Sectors of Chandigarh City. Figure 2 depicts the distribution of population and SBAs.
Table 4: Ratio of skilled Birth attendants and population in Chandigarh City.
Sector No. Population Ratio No. of SBAs
|
| Sector No. Population Ratio | 30. | 1 | 11045 | 1 : 11045 | |
| No. of SBAs | 31. | 0 | 6662 | – | |
| 1. 0 149 – | 32.* | 405 | 11288 | 1 : 28 | |
| 2. 0 554 – | 33. | 13 | 6964 | 1 : 536 | |
| 3. 3 335 1 : 112 | 34.* | 105 | 5015 | 1 : 48 | |
| 4. 1 688 1 : 688 | 35. | 9 | 12714 | 1 : 1413 | |
| 5. 0 596 – | 36. | 4 | 4254 | 1 : 1064 |
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Health Institute. Source (2001) – Statistical Branch, Census Office, Chandigarh (Unpublished)
Figure 2 : Distribution of Population and Skilled Birth Attendants in Sectors of Chandigarh
Discussion
Ensuring prospective mothers an equitable access to skilled care is acknowledged as a universal human right. In 1999 a joint WHO/ UNFPA/UNICEF/World Bank statement 7 called on countries to ensure that all women have skilled care during pregnancy, child bir th and immediate postnatal care. With only 48.2 per cent of births conducted by skilled birth attendants15, India still has a long way to go to match the achievements of the developed countries.
The present study was conducted in Chandigarh city which has a vast network of health facilities including Government and Private hospitals, Civil Dispensaries and private clinics. According to 2001 Census, the Union Territory had a total population of 9,00,635 including 8,08,515 (89.8 per cent) living in urban areas14. Projecting these figure to 2009, the present population of Chandigarh City is estimated to be 11,25,000. In the present study it has been found that there were a total of 2261 Skilled Birth Attendants (SBAs) available in the City. Thus, the ratio of SBAs to population was 1:497. The availability of SBAs in Chandigarh City was certainly better than proposed by the International Confederation of Midwives (ICM) and International Federation of Gynecology and Obstetrics (FIGO) which is 1:5000 16. This was in complete contrast to South East Asia and Sub-Saharan Africa where only one SBA was available for every 300,000 people 10.
Regions within the country often vary considerably15. Such variations were found in the present study also. The SBAs were not evenly distributed in the Chandigarh City. Sector 12 had the maximum number and also the most qualified SBAs. This is due to presence of PGIMER, a premier health care organisation. Similarly, Sector 32 and Sector 16 having leading Government Hospitals also had large number of SBAs i.e. 405 and 100 respectively. Sector 34 was the only Sector having maximum number of Private Hospitals. There were 7 Sectors which had only 1 Health Care Facility and Sectors 2, 5, 39 and 57 to 63 did not have any such Facility.
Studies show that the availability of SBAs at the institutional set up did not always guarantee availing services and home deliveries were still preferred by many 17. The latest statistics of NRHM had revealed that 3383 home deliveries have taken place in Chandigarh during 2008-09 18. Earlier Gupta et al.12 found that 68 per cent deliveries were not assisted by SBAs in urban slums in Chandigarh. This was happening in spite of ample Government and private health care facilities available within easy reach and very favorable SBA to population ratio (1:497).
Though 2261 SBAs were available in Chandigarh City, all of them were not used as skilled bir th attendants. In government hospitals they were used in different departments on rotation basis and were able to provide skilled attendance only when posted in maternity wards and labour rooms. In private sector also the qualified nurses were utilized for providing bed side nursing and only maternity homes were utilizing them as SBAs. There is a need to revise regulations and administrative procedures to ensure a shift of responsibility for care among current health providers to the level where it is most needed.
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