Strengthening the Capacity of Auxiliary Nurse Midwives (ANMs) in India

Introduction 
The Centre for Maternal and Newborn Health (CMNH) and the Foundation for Research in Community Health are currently working together on a programme to improve the quality of care provided by auxiliary nurse-midwives (ANMs) in the Pune district of Maharashtra State, India. We anticipate that through this approach, ANMs will be enabled to fulfil their full potential to address the primary healthcare needs of the population.

Brief background
ANMs are a vital part of the primary health services. ANMs are needed in the context of India because the existing health services cannot meet the health needs of the population. The Indian government has long invested in ANMs to provide care during and after pregnancy and childbirth and to provide basic curative and preventive child health services. Yet, over time, the ANM’s role has expanded with less focus on maternity care. Furthermore, although ANMs have been used for decades as frontline workers, they often stand unsupported at the fringes of the health system, and thus unable to fulfil their full potential in catering to the primary healthcare needs of the population.

Project activities
Through this programme, CMNH aimed to:

  • Examine factors influencing ANMs in their practice, scope of work and workload
  • Explore the views of key stakeholders involved in training and deployment of ANMs
  • Understand if and how this cadre can be supported in future to make an effective contribution to the delivery of healthcare for women and children at the primary level in the Pune district
  • Develop a context-specific ANM training package and strengthen supportive supervision, involving up to 50 ANM supervisors and 400 ANMs across different blocks of Pune district.

Outputs to date
Through our initial scoping activities, we confirmed that ANMs have played a pivotal role in primary health care within the district and are an indispensable asset to the primary health services. However, there are missed opportunities as the full potential of ANMs has not been utilised. For example, in remote, poorer areas of the Pune district, women have not benefited in the same way as those in urban settings. In remote areas, ANMs did not have the necessary skills to provide quality services - mostly due to lack of regular, refresher training to update their knowledge and skills. 

We are now working with the government of Maharashtra State to improve the quality of work of ANMs through various activities. These include delivering context-specific training of ANMs and their supervisors, addressing gaps and weaknesses identified, and strengthening supportive supervision and accountability, and empowerment through learning:  

  • We developed a training package in response to expressed needs in maternal and newborn health and other areas, which has been reviewed and approved by the Government of Maharashtra State.
  • We have developed a core group of trainers who now conduct training (skills and drills, presentations, etc) using this training package.  
  • A few ANMs have been taken to centres of excellence in neighbouring states to interact with staff working in those centres. Some have presented their experiences in national conferences.  
  • We have also held a recent skills mall for ANMs in Pune, where ANMs could learn life-saving skills such as newborn resuscitation, management of obstetric haemorrhage, shoulder dystocia and breech, maternal mental health & communication skills.

Outcomes from this research programme will provide evidence to inform policy and practice both in Pune district and India. The insights from this study can be transferred to similar primary level healthcare providers to improve availability and quality of health for mothers and children.