The first time Auxiliary Nurse Midwife (ANM) Beena encountered a 14-day-old newborn who needed injectable antibiotics, she understood the meaning of facing one’s fears. “I had been trained on correctly identifying babies needing injectable gentamicin and had the protocol and the medicines with me,” said Beena. “But when I saw this small baby and realized he needed injectables, I froze.” Beena then turned to her mentor at the Vriddhi project. She received the guidance and assurance she needed to do the right thing—administer the injectable antibiotic before the baby’s condition worsened or the family decided to consult an untrained informal health care provider.
Through the Vriddhi project, JSI is facilitating the use of injectable gentamicin by ANMs in accordance with recommendations from the Government of India. One of Vriddhi’s project sites—block Roorkee in Haridwar district in the northern Indian state of Uttarakhand—is home to over 300,000 people and has seven primary health centers (PHCs). That is a rate of one PHC for close to 43,000 people—nearly double the normal ratio of one PHC for 20,000 to 30,000 people—making Roorkee’s ANMs crucial for delivering health services in their block. JSI has trained all 32 ANMs in Roorkee on how to identify sick newborns and deliver lifesaving interventions such as Kangaroo Mother Care and the administration of injectable gentamicin when appropriate.
While ANMs showed improved knowledge scores post-training, both informal and formal peer support structures have developed to allow ANMs to share experiences and advice. Beena reports that five of her colleagues have called her in the last few months expressing the same hesitancies she initially faced when administering injectable gentamicin. “They are generally seeking reassurance but once in a while there are questions like, ‘[The] baby’s weight is 1.5 kgs; should injectable gentamicin be given?’ or ‘What is the cut-off temperature for hypothermia?’” she said. In these instances, Beena remembers what she learned in her training. She informs her peers that gentamicin should not be administered to low birth weight babies in the community setting. Additionally, the babies should be referred immediately if any danger signs are present, such as armpit temperature dropping to 97.6˚F or below. She also encourages her peers to refer to the training materials provided through Vriddhi.
Vriddhi’s project team recognizes the need for continuous motivation and support for ANMs after training to ensure they feel comfortable administering injectable antibiotics to newborns. During monthly meetings, ANMs, like Beena, who have been successful in identifying eligible cases and administering the lifesaving injection share their stories. This creates a space where other ANMs feel comfortable discussing the challenges they face and reaching out to experienced ANMs when they need support.
These formal and informal support systems are critically important to meeting the ANMs’ support and guidance needs. Under India’s public health system, the lady health visitor (LHV) is the first line supervisor for ANMs. An LHV is usually a promoted ANM who receives an additional six months of training and gains supervisory responsibilities for 5–6 ANMs. However, in places like Roorkee, for example, there are only three LHVs to supervise the block’s 32 ANMs, creating additional demands on LHVs to support ANMs in their communities. An ANM’s second line supervisor is the medical officer in her local PHC, but ANMs are often less comfortable seeking guidance from medical officers who also have limited time available for discussion with ANMs. To mitigate gaps in support, Vriddhi has informally encouraged peer support through experienced ANMs, like Beena, and is also working with formal supervisors to proactively address the needs of ANMs and empower them to deliver lifesaving care in the communities they serve.