The document discusses advocacy efforts in India to increase skilled birth attendance. It notes that about 70,000-100,000 women die during childbirth in India each year. The White Ribbon Alliance for Safe Motherhood India initiated an advocacy campaign to increase skilled attendance at birth. This included gathering evidence, developing guidelines, empowering Auxiliary Nurse Midwives as skilled birth attendants, and advocating for policy implementation with various stakeholders. Tracking efforts found that policies have had varying levels of success in different states and more work is still needed. Continued community-centered advocacy is advocated to help reduce maternal mortality.

1. ““Advocacy for PolicyAdvocacy for Policy
Development andDevelopment and
Implementation”Implementation”
Dr Aparajita GogoiDr Aparajita Gogoi
National Coordinator, WRA IndiaNational Coordinator, WRA India
& Senior Advisor, Advocacy and& Senior Advisor, Advocacy and
Communication,Communication,
CEDPA/IndiaCEDPA/India

2. Maternal Health In IndiaMaternal Health In India
• In India, about a 70,000 toIn India, about a 70,000 to
100,000 women die every100,000 women die every
year due to pregnancy oryear due to pregnancy or
child birth relatedchild birth related
complicationscomplications
• India’sIndia’s MMR is estimated toMMR is estimated to
be 301 maternal deaths perbe 301 maternal deaths per
100,000 live births.100,000 live births. i.e. onei.e. one
woman dies every sevenwoman dies every seven
minutesminutes
• We are nowhere nearWe are nowhere near
achieving the target set byachieving the target set by
Millennium DevelopmentMillennium Development
GoalsGoals

3. Today, in India…
• About 60% deliveries take placeAbout 60% deliveries take place
at homeat home
• Almost all 60% are conductedAlmost all 60% are conducted
by unskilled attendantsby unskilled attendants
• Institutional deliveries are onlyInstitutional deliveries are only
around 40%around 40%

4. Advocating for Skilled Attendance atAdvocating for Skilled Attendance at
BirthBirth
Therefore,
The White Ribbon Alliance for Safe Motherhood
India (WRAI) initiated an advocacy campaign
for increasing Skilled Attendance at Birth
The WRA, India was established on November
12th, 1999, when CEDPA, an International
NGO, called a meeting of all stakeholders and
introduced the concept of working collectively to
reduce maternal deaths in the country

5. What did we do?
Gathered evidence and information:
– Compared WHO midwifery standards of Practice to Indian
nursing standards and verified major gaps in skills and
practice
Made a case:
– Reviewed the legalities of the re-assignment of life saving
skills to different levels of health, prepared a technical
paper, presented findings to MoHFW
Found allies:
– Convened a series of meeting to begin a process of
consensus building
Conducted Parallel Advocacy Campaigns
– “Ensure Skilled Attendance at Delivery”

6. Invitation by Ministry of Health and FamilyInvitation by Ministry of Health and Family
WelfareWelfare
• In mid 2004, the MoHFW invited the WRAI to lead a process
of consensus building on reassignment of life saving skills
• Recommendations were submitted to MoHFW
• Some examples:
– Tab. Misoprostol, Start IV infusion in all cases of PPH
before referral, Inj. Magsulf (IM) for controlling eclamptic
fits, first dose of Gentamycin/Ampicillin and
Metronidazole orally before referring for prevention of
infection
– Certain procedures were also recommended
• Recommendations were accepted and the changes were
included in the National RCH Policy Documents

7. Guidelines Developed & ReleasedGuidelines Developed & Released
In collaboration With MoHFW, UNFPA, WHO India, FOGSI and
many others, the following were developed
(1) Guidelines for Ante-Natal Care and Skilled Attendance at
Birth by ANMs, LHVs and Staff Nurses
(2) Guidelines for pregnancy care and management of
common Obstetric Complications by Medical Officers
(3) Guidelines for Operationalisation a Primary Health Center
for providing 24 hour Delivery and Newborn care under
RCH-II

8. Auxiliary Nurse Midwives asAuxiliary Nurse Midwives as
Skilled Birth AttendantsSkilled Birth Attendants
• Auxiliary Nurse Midwives have nowAuxiliary Nurse Midwives have now
been legally empowered to be Skilledbeen legally empowered to be Skilled
Birth AttendantsBirth Attendants
• They are now permitted to administerThey are now permitted to administer
specific life saving drugs andspecific life saving drugs and
perform life saving interventionsperform life saving interventions
under clearly specified situationsunder clearly specified situations

9. Will the scenarioWill the scenario
change once policieschange once policies
are in place??are in place??

10. Advocacy for ImplementationAdvocacy for Implementation
WRA India is engagingWRA India is engaging
•parliamentariansparliamentarians
•elected representativeselected representatives
•and media representativesand media representatives
..in advocacy for implementation of these..in advocacy for implementation of these
policies and programs at national and statepolicies and programs at national and state
levelslevels

11. Advocacy with Civil Society
Civil societyCivil society
organizationsorganizations
trained ontrained on
conducting policyconducting policy
advocacy toadvocacy to
– key decisionkey decision
makersmakers
– MediaMedia
– CommunityCommunity

12. Advocacy with Elected RepresentativesAdvocacy with Elected Representatives
At three levels:At three levels:
– Members ofMembers of
ParliamentParliament
– Members ofMembers of
LegislativeLegislative
AssembliesAssemblies
– Panchayati RajPanchayati Raj
representativesrepresentatives
Main Interventions:Main Interventions:
– Issue Sensitization-Issue Sensitization-
Advocacy Kit &Advocacy Kit &
workshopsworkshops
– Enroll as advocates orEnroll as advocates or
championschampions
– Involvement inInvolvement in
tracking thetracking the

13. Advocacy with the MediaAdvocacy with the Media
At three levels:At three levels:
– National LevelNational Level
– State levelState level
– District and ZonalDistrict and Zonal
levelslevels
Main Interventions:Main Interventions:
– Issue SensitizationIssue Sensitization
– Highlighting the roleHighlighting the role
media can playmedia can play
– Providing data, storyProviding data, story
ideas, facilitatingideas, facilitating
reporting; field visitsreporting; field visits

14. People centered advocacyPeople centered advocacy
• At the community level:At the community level:
Public hearings, rallies,Public hearings, rallies,
contests, etccontests, etc
• At the district level:At the district level:
Discussions held on theDiscussions held on the
district advocacy plans,district advocacy plans,
local issues, sharing oflocal issues, sharing of
district level facts anddistrict level facts and
figures sharingfigures sharing
• Submission of memoranda,Submission of memoranda,
asking for regularasking for regular
availability of specialistavailability of specialist
doctors at CHCs anddoctors at CHCs and
training of ANMs in Skilledtraining of ANMs in Skilled

15. Tracking Implementation of policies and
programmes
In Rajasthan,
WRA Rajasthan
assessed…..
• 226 Sub Centre for SBA
training using IPHS
guidelines
• 607 women interviewed for
services received from the
ANMs

16. Examples of Findings..
Of the 226 Sub centre assessed
• 62 % Sub centres were not ready for the SBA training
in terms of infrastructure, access and supplies
• 70% Sub centre s did not have ANMs staying 24x7
• 58% ANMs did not assist in childbirth.
• 95 % women mentioned that it would be useful if the
ANM received skilled based training

17. Tracking implementation of
policies in Orissa
• WRAI has also devised checklists for Elected
Representatives and Civil Society organizations
to track the implementation of national policies
and programs at the district level
• Trained NGOs in the use of these checklist to
carry out a social watch
• Used the findings to increase accountability of
Elected Representatives and Government
officials

18. Examples of findings
• Out of 12 First Referral Units, covered
under the study, only 2 FRUs in were
functional
• Shortage of doctors and staff made First
Referral Units dysfunctional
• Wide disparity between districts-some
districts were able to implement the
policies and programmes well

19. Verbal Death Audits
• WRA Orissa has been conducting
verbal audits of maternal deaths
• Report the findings to the government
• Use the findings to advocate both at the
health facility and community level

20. The Way ForwardThe Way Forward
• Continue the people centeredContinue the people centered
advocacyadvocacy
– Campaign launched onCampaign launched on
National Safe MotherhoodNational Safe Motherhood
Day 2007-”Know yourDay 2007-”Know your
Entitlements”Entitlements”
• Continue working ElectedContinue working Elected
Representatives, especially atRepresentatives, especially at
the Panchayat level-the Panchayat level-
• Continue working with theContinue working with the
mediamedia
• Continue skill building ofContinue skill building of
grass root partners ingrass root partners in
advocacy and communityadvocacy and community
mobilization around safemobilization around safe
motherhoodmotherhood

21. In ConclusionIn Conclusion
These policy changes,These policy changes,
when implementedwhen implemented
nationwide, willnationwide, will
increase access toincrease access to
skilled attendance atskilled attendance at
birth and emergencybirth and emergency
obstetric care and thusobstetric care and thus
decrease maternal anddecrease maternal and
new born mortalitynew born mortality