KANKER (Chhattisgarh): Doctors Kiran Lata Thakur, Hemlata Sahu and Ujjwala Devangan have more than one thing in common. Other than being doctors at the Komal Dev Government District Hospital in Kanker, the three are Master Trainers who have the responsibility of training the doctors for providing safe abortion services.
Chhattisgarh is predominantly tribal-dominated State with 35% of its population being Scheduled Tribe with high a maternal mortality ratio (MMR) of 221/100000 live births in 2011-2013 and an unofficial rough estimate suggests that anywhere between 10,000 to 60,000 abortions are conducted in the State every year. In India, unsafe abortions cause 8 to 10% maternal deaths.
The Master Trainers conduct the trainings for other doctors at the Comprehensive Abortion Care (CAC) Training Center developed by in collaborations with Ipas Development Foundation (IDF) – a non-government organization working on safe abortions. Ipas began its operations in the State in 2014 and chose Kanker District Hospital as one of the 6 Training Centres.
Before 2014 there was no separate facility for training on safe abortions as it was not a priority in the health sector. But now with safe abortions being an integral part of the National Health Mission (NHM) and Ipas being a critical partner, Kanker District Hospital has a dedicated training room where doctors from the health facilities in Northern Bastar are trained in the batches of twos. The training room has posters, relevant literature on safe abortion, a chart with the course outline and dummy pelvic model for training.
“During training if there is an abortion case, we take the doctors to the theatre for a hand-on training as well,’’ explains Dr Kiran Lata Thakur.
While the training of trainers (ToT) is 3-4 day programme for Registered Medical Practitioners mostly obstetricians and gynecologists who are adept at this procedure, the focus in the ToT is to orient them on new technologies and methodology for facilitating training. This programme is run by IDF staff in the States that IDF works in but also facilitated in other States on request. The certification training of MBBS doctors is for 15 days and is executed by the State trainers trained in the ToT. The IDF teams are involved at various stages in planning and execution of these trainings which are budgeted under the NHM.
Once the doctors are selected for the training, mainly depending on the caseload in their respective facilities and preferably from delivery points, they come to Kanker District Hospital where they are made to undergo a pre-qualification test to assess the trainees on their knowledge of the subject. They have to undergo the same test post-training for evaluation.
“Our experience shows that young doctors are more knowledgeable with a fair understanding of the Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) programme of which safe abortion is a part,’’ says Dr Thakur.
The training includes sessions on laws such as Medical Termination of Pregnancy Act, 1971; Protection of Children from Sexual Offences Act, 2012, Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994, human rights, health rights infection prevention and reproductive rights of individuals in addition to theory and hands-on trainings on conducting safe abortions.
Once trained, each certified doctor is given a Manual Vacuum Aspiration (MVA) kit and the facility is provided IEC material to educate and inform the community about the availability of services.
After the training, IDF and Master Trainers provide all kind of support to the trained doctors. There is a proper schedule which is followed for this. The trained doctors receive a call from IDF within 28 days after they go back to their respective facilities to check on the progress. This is followed by a visit to the facility within 60 days. Calls and visits are also conducted based on the needs of the provider as well including for clinical support.
“As many as 88 doctors have been trained at Kanker since 2014 and all of these have been providing safe abortion services at their facilities. However, there are occasions where the doctors have some reservations on conducting abortion which could either be personal or religious or even hesitate to perform the procedure. In such cases, we just ask them to use Medical Methods of Abortion (MMA) wherein drugs are given and ask them to perform vacuum aspiration in case of an incomplete abortion. This helps them get over hesitation/resistance and even gives them experience,’’ says Dr Thakur.
Ipas Development Foundation has developed six training centres across Chhattisgarh. These were selected on the basis of a baseline survey conducted at 236 public health facilities done at District Hospitals, Community Health Centres and Primary Health Centres. An assessment was done for availability of human strength, skill, training requirement, availability of basic minimum infrastructure necessary for providing CAC services, and availability of instruments and consumables. Also taken into consideration is the current awareness, knowledge and attitude of the providers towards the legal aspects of abortion and related services.
“Kanker has banned over-the-counter sale of abortion drugs within the city that has greatly reduced cases of incomplete abortions. Women have also given up adopting traditional methods of abortion which are unsafe and this has happened because of awareness created by frontline health workers and IEC material provided by the government. However, the coverage of CAC services should be complete but there are several areas where we are yet to reach,’’ says Dr. R.C. Thakur, Civil Surgeon at the Kanker District Hospital.
Comprehensive Abortion Care training is being rolled out in phased manner in Chhattisgarh with District Hospitals and First Referral Units to be covered in the first phase followed by Community Health Centres in the second phase and finally the 24X7 Primary Health Centres. Six District Hospitals at Kanker, Surguja, Bilaspur, Durg, Rajnandgaon and Raigarh have been developed as CAC Training Centres where doctors are imparted training on safe abortion and the nursing staff on counselling and MTP supporting services. And, the progress so far has been outstanding with the District Hospitals providing CAC services going up from 16 in 2009 to 23 in 2016; CHCs providing safe abortion services going up from 19 to 127 and PHCs from 1 to 48 during the same time. Kanker has four Master Trainers, three posted at the District Hospital and the fourth at the Bhanupratappur CHC.
“Much has changed now. We have very few cases of perforated uterus and very few women come here in critical condition now as a result of unsafe or incomplete abortions. Mitanins have had a role to play in creating awareness about the safe abortion services in the hospital. Those who come here are mainly those of accidental pregnancies due to contraception failure or incomplete abortions,’’ explains Dr Ujjwala Devangan. Teenage pregnancy is also an issue and the doctors can only counsel the young women to use contraceptives by educating them on the adverse impact of repeated abortions. “At times, women who come here have very low haemoglobin levels and most of them are referred here from nearby areas because this hospital has a Blood Bank facility,’’ Dr Devangan says.