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Research Article

Nurses and midwives

Public Health Review - International Journal of Public Health Research

2022 Volume 9 Number 1 January February
Publisherwww.medresearch.in

Lived experiences of nurses and midwives about pregnancy and childbirth care among tribal women at secondary level health care facilities of Madhya Pradesh, India

Verma M.1*
DOI: https://doi.org/10.17511/ijphr.2021.i01.01

1* Mamta Verma, PhD scholar, , Tata Institute of Social Sciences, Mumbai, Maharashtra, India.

Introduction: Tribal communities are distinct across the India and state of Madhya Pradesh. There are few shreds of evidence that addressed the inadequacy of health status in the tribal population as compared to the non-tribal population. Pregnancy and childbirth care is compounded by issues like poor nutrition and the education level of girls. Suboptimal access to maternal health services due to traditional beliefs, violence against women and substance abuse are significant. Objectives: This study is focused to explore and understand the experiences of nurses in maternity care catering to the tribal population. Material & Methods: A phenomenology study was conducted. Two community health centres from a tribal district were selected. Six in-depth interviews were carried out to probe the experiences of nurses, data were analyzed using ATLAS.ti 8 software. Results: Major themes that are reflected by nurses are difficult transportation, the high volume of normal vaginal deliveries, initial experiences of conduction of normal and assisted delivery, social and professional isolation and traditional tribal practices of pregnancy and childbirth. Conclusion: Understanding the nurses’ experiences are sufficient evidence to render culturally oriented maternity care and reform the tribal public health system.

Keywords: Experiences, Nurses and midwives, Pregnancy and childbirth, Tribal women, Community health centres, Madhya Pradesh

Corresponding Author How to Cite this Article To Browse
Mamta Verma, PhD scholar, , Tata Institute of Social Sciences, Mumbai, Maharashtra, India.
Email: 		Mamta Verma, Lived experiences of nurses and midwives about pregnancy and childbirth care among tribal women at secondary level health care facilities of Madhya Pradesh, India. Public Health Rev Int J Public Health Res. 2022;9(1):1-6.
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https://publichealth.medresearch.in/index.php/ijphr/article/view/178

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-01-15 2022-01-17 2022-01-24 2022-01-31 2022-02-07
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2022by Mamta Vermaand Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Verma M: Lived experiences of nurses midwives about pregnancy childbirth care tribal women

Introduction

Tribal communities are distinct because of primitive traits, cultural uniqueness & geographical isolation [1]. The tribes in India constitute 8.2% with a population of 84,326,2402.  About 21.1 per cent of the Madhya Pradesh state population is tribal [2,3]. It is the state in India where every fifth person belongs to a tribal community [3]. Out of 51 districts, 21 districts of this state are considered tribal districts [3,4]. The total number of tribal people is 15,316,784. Their literacy rate is 50.55 per cent, and the sex ratio is 984 [4]. The Bhils, Gonds, Kols, Saharias, Korkus Baigas, Bharias are the classical types of tribal communities of Madhya Pradesh [5].

Several researchers and reports have reported inadequacy of health status in tribal populations as compared to the non-tribal population [1,6]. Maternal and newborn health services are challenging due to the exceptional health-seeking behaviour of tribal communities and lack transportation facilities [1,6]. It is pertinent to deliberate that the Quality of maternal care is low in tribal areas [6,7]. Full antennal care coverage is poor among tribal women. About 27% of tribal women still deliver at home [6-8]. It is also observed that the rate of institutional delivery is low as compared to other social groups [6]. Only 72.7% of tribal women were assisted by skilled birth attendants [6]. Anemia and post-partum haemorrhage are two leading causes of maternal mortality among tribal women6. About 20% acceleration of infant mortality was evident as compared to the non-tribal population [6]. Community health centres are secondary level public health care facilities at the subdistrict level. It is a 30-bedded hospital. It has specialist doctors besides 10 staff nurses [10]. They are expected to provide all basic and emergency obstetrics care [10]. The tribal areas of Madhya Pradesh need 178 Community health centres. There are only 104 as of now, a shortfall of 74 Community health centres [9].

Nurses and midwives render patient-centred care in the proximity of the community [11]. In most instances, nurses are the most accessible primary health care professionals who can be approached by the public [11]. The rural health care system facing an acute shortage of nurses [12]. It is

more worsen in the tribal area, a shortfall of nurses in the tribal area was 27.9% while in all India it was 20.2%6. Nurses had intense levels of stress and responsibility [1,8].

Therefore, this study was planned to understand the experience of nurses while working in tribal community health centres of Madhya Pradesh.

Material & Methods

Study sites: The study was conducted in the Madhya Pradesh province of central India. A tribal district was selected from the Bhopal division. Two Community health centres were selected based on the Health Management Information System (HMIS) indicator “the percentage of institutional deliveries to total ANC registration in the year 2018- 2019” [13].

Participant’s selection criteria: Nurses midwives who had general nursing and midwifery diploma or B.Sc. Nursing or post basic B.SC. Nursing and R.N.R.M. registration were enrolled in the study. Additional criteria for the selection of the participants were based on the length of the experience in maternal and newborn care units. Three strata of experiences were decided 1- Experience more than 10 years, category 2- Experience between 5 to 10 years, category 3- Experience less than 5 years. Two pilot interviews were conducted. A total of six in-depth interviews were conducted for the study.

Research study methods: It was a phenomenology study. The interviews of target Nurses were planned to understand the experience of nurses while working in tribal community health centres of Madhya Pradesh. A Semi-structured interview guide was prepared based on the review of literature and observations of the daily routine of nurses, Initiation of the Interview followed by the main phase of the Interview, the questioning phase of the Interview and ended with concluding talk. In-depth interviews of nurses were conducted between May to December 2019. The duration of each interview ranged from twenty to sixty minutes. All interviews were conducted at the health facilities and in the Hindi language. Each interview was audio-recorded and transcribed by the researchers.

Ethical considerations: Appropriate administrative approval was obtained to conduct the study. Written informed consent


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was taken from each participant who had observed and was interviewed in the study. The data collected from participants were kept confidential. To ensure confidentiality and anonymity, interviews were held in participants’ preferred rooms in community health centres.

Trustworthiness: It was ensured by following Guba’s (1985) four criteria credibility, Transferability, dependability and conformability [14].

Analysis: A total of six in-depth interviews were analyzed by ATLAS.ti 8 qualitative data analysis software. It was accomplished by phases of exploration, organization, analysis and interpretation.

Results

Demographic distribution of the participant’s profile: Most of the participant’s ages varied between 29 to 65 years and had G.N.M. diploma qualifications. All the respondents were female nurses and midwives. Their experience also varied from 2 to 45 years.

Reminiscence: Experienced nurses recollected their experiences and described the transition in care over the years.

“Earlier rate of delivery was less. Now the number of institutional deliveries has increased as the government is offering many facilities. Now we deliver between 100 and 150 deliveries per month.”

Access to health services in tribal areas is more difficult due to the challenging geographical landscape and poor transport facilities.

“I used to wade through the river up to my neck level. I went into a single dress and returned in the same salwar kameez dress in eight days. I worked in dense tribal areas for 10 to 12 years”

Conduction of normal vaginal delivery: Although new and not well prepared for her first delivery at a tribal Community health centre, a nurse said she did as best as she could.  

“I was alone when I conducted my first delivery. I was new. I did know what to do as the mother was in full dilatation and the baby’s head was coming out. I held the baby’s head first and clamped and cut the umbilical cord”

Nurses in tribal Community health centres manage obstetric emergencies such as twin and breech presentation delivery. Successful management of such cases is challenging for nurses but it enhances their self-confidence. A respondent expressed that she manages complicated delivery cases.

“Tribal women generally do not prefer sonography scan in the antenatal period. Nurses, when conducting such women’s delivery in Community health centres are unaware of the number of fetuses and fetal lie position in the uterus “.

“I conducted a breech delivery. I did her per vaginal examination. I delivered the baby comfortably as it was of low birth weight. I have delivered twins babies also.”

Managing PPH cases for nurses at tribal is crucial.

“Blood was flowing like tap water despite using cotton pads and gauze pieces. The doctor and I administered the drug and managed to control the bleeding and we saved the life of the woman.”

Experience of newborn care: Tribal communities prefer the male child over the female one. Aware of the preconceived bias against the girl child, It is worthful to note that nurses do not disclose the sex of the baby immediately after delivery.

“When a woman came to know that she had delivered a girl child for the third time, she started crying loudly, because of family pressure.”

 A participant reported that they facilitate the early initiation of breastfeeding. Nurses ensure a safe and aseptic environment in the postnatal ward.

“In cases of low-birth-weight babies, we often explain the importance of breastfeeding. We do not allow an attendant to sit on the mother’s bed because it may cause infection to the newborn.”

Multitasking experience: Multitasking is a risk taken by nurses in remote tribal areas. The nurse wishes she had more human resources so she could provide critical care in an emergency.

“When I am trying to resuscitate a newborn baby, and at the same time a mother undergoes PPH. There is no one to help me in these circumstances. If I have to refer a patient to the next higher level, my hands are soiled and I have to make a telephone call to arrange a vehicle for transportation”



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Verma M: Lived experiences of nurses midwives about pregnancy childbirth care tribal women

Social Isolation: A respondent said she lives away from her husband and young children due to her job. She visits her home on her weekly off day. This puts a strain on the whole family.

“I don’t like working here (pause). I live here alone away from my family. I want to be transferred from here and be with my children.”

Professional expectations: Experienced and senior nurses expressed their concern about promotion opportunities and career development.

“Many times, I felt I should go for higher education and get promoted”

“New higher post should be created for nurses at Community health centres level.”

Tribal communities’ rituals and culture: The woman has a low status in tribal communities, according to a respondent. Pregnant women are more vulnerable. Due to backwardness and poverty, tribal women are not keen to deliver babies at Community health centres.

“Many tribal women do not wish to come to the hospital. They come with a single cloth on their body, escorted by ASHA workers, who work in tribal areas of extreme poverty.”

Financial incentives for institutional deliveries are often is-utilized by patients and families.

“The money the postnatal women get for institutional delivery is spent by their husbands on buying alcohol. The entire money is wasted on alcohol, which is also consumed by older women in the family.”

A participant observed that tribal women remain strong in the normal birthing process.

“Tribal women are very courageous. They may not consume nutritious food in pregnancy but they show tremendous power and courage in the labour process.”

A respondent expressed concern about safety during night shifts in tribal areas. A nurse has to deal with such intoxicated people alone in night shifts. This situation is difficult to manage.

“During night tribal men and women consume alcohol and come to the hospital and abuse us.”

Women opt more than men for permanent family planning solutions.

“Here couples adopt family planning only if they have a male child. Tubectomy is preferred over vasectomy as a method of family planning.”

Mothers, even when admitted to the labour room, follow their tribal rituals and cultural practices to ease the labour process. Participants threw light on these tribal rituals.

“Bhagat Bhumika, a religious guru, offers seeds and thread to women in labour and chants some mantras to accelerate the labour process. Many tribal people offer a brew of Jadi booty` (the root of a plant) to a woman in labour pain. They believe it accelerates dilatation which induces labour”.

Discussion

The results of the study have yielded insights like the high number of delivery load, safety issues and poor transportation facilities. Similar findings are reported in another study [7, 15, and 16]. The present study also explores nurses’ experience in conducting normal vaginal delivery. Respondents reported that they learn it during the job under the guidance of a senior nurse and manage completed cases. Findings of an institutional ethnography “how rural nurses learn to provide maternity care” are in the line of this study [16]. The most striking finding of this study is that financial incentives for institutional deliveries are often spent by patients and families in other utilities rather than mother and newborn health. It is confirmed by one of the latest reports published by the government of India [6]. Gender preference does prevail in tribal communities and reported by participants and another study [7]. A researcher found that “immediately after birth, the newborn baby is cleaned with a clean, soft, old used cloth and put to the breast” [18].

This study also highlighted that tribal women were under-utilizing the health facilities. As a general practice, pregnant tribal women do not get their sonography done. Sengupta (2019) reported the diet preference of antenatal women. He found that local citrus food and rabbit meat is consumed during pregnancy18. Some authors observed that low educational background and poor transport facilities were responsible for poor access to a health care facility in tribal areas [1,7]. One of the tribal rituals related to the labour process reported by this study is “Bhagat Bhumika’’ a traditional


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labour acceleration consultation. Similar findings have been illustrated that in some tribal communities commonly performed traditional rituals include “putting oil drops on the abdomen to assess uterine contractions and predict the time of delivery”. In some places, tribal women deliver in a squatting position. In most instances’ the female family members of the pregnant woman first discuss with their local physician who decides if the nurse should be called or not, [8, 18]. There is a necessity to awaken maternal health services, to be open to the requirements of tribal women, adapt to their cultural needs [19, 20].

Conclusion

Many tribal faith-based practices exist to accelerate the labour process. Transcultural maternal and newborn care must be incorporated in the nursing course curriculum and practices to enhance the acceptance of nurses by the local communities. Tribal community centres are an excellent source of learning about vaginal births as maternal and newborn care cases are in abundance. Nurses are advocating evidence-based transcultural natural birthing skills. Interview results of nurses depict that nurses desired a clear career progression pathway in their service period. Policymakers should consider this aspect.

This study was a tiny step towards recognizing tribal nurses’ contribution to maternal and newborn care.

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