Where there is no obstetrician - increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors

Background: Maternal mortality continues to be high in rural India. Chief among the reasons for this is a severe shortage of obstetricians to perform cesarean delivery and other skills required for emergency obstetric care (EmOC). In 2006, the Government of India and the Federation of Obstetric and Gynecological Societies of India (FOGSI) with technical assistance from Jhpiego, instituted a nationwide, 16-week comprehensive EmOC (CEmOC) training program for general medical officers (MOs). This program is based on an earlier pilot project (2004-2006). Objective: To evaluate the pilot project, and identify lessons learned to inform the nationwide scale-up. Methods: The lead author (CE) visited trainees and their facilities to evaluate the project. Eight data collection tools were created, which included interviews with informants (program/government staff, regional/international experts, trainees and trainers), facility observation, and facility-based data collection of births and maternal/newborn deaths during the study period. Results: More trainees performed each of the basic EmOC skills after the training than before. After training, 10 of 15 facilities to which trainees returned could provide all signal functions for basic EmOC whereas only 2 could do so before. For comprehensive EmOC, 2 facilities with obstetricians were providing all functions before and 2 were doing so after, even though the specialists had left those facilities and services were being provided by CEmOC trainees. Barriers to providing, or continuing to provide, EmOC for some trainees included insufficient training for cesarean delivery, lack of anesthetists, equipment and infrastructure (operating theater, blood services, forceps/vacuum, manual Vacuum aspiration syringes). Conclusion: Although MOs can be trained to provide CEmOC (including cesarean delivery), without proper selection of facilities and trainees, adequate training, and support, this strategy will not substantially improve the availability of comprehensive EmOC in India. Recommendations: To implement a successful nationwide scale-up, several steps should be taken. These include, selecting motivated trainees, implementing the training as it was designed, improving support for trainees, and ensuring appropriate staff and infrastructure for trainees at their facilities before they return from training. (C) 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.