Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
The Foundation for Research in Community Health, Aundh, Pune, Maharashtra, India.
PLoS One. 2019 Dec 27;14(12):e0226831. doi: 10.1371/journal.pone.0226831. eCollection 2019.
The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India.
Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs' performance as a result of "mechanisms" (training, supervision, accountability mechanisms) within the given "context" (regulatory system, infrastructure and resources, ANMs' expanded scope of work, gender roles and norms).
Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving.
Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India.
助产妇（ANM）干部的设立是为了专注于母婴健康。ANM 是社区中受人尊敬的成员，也是社区和医疗机构中母婴保健服务的主要提供者。随着时间的推移，又增加了一些其他的角色和职责。尽管 ANM 在印度的初级医疗保健系统中非常重要，但考虑到影响其工作表现的因素的研究是有限的。我们旨在研究印度浦那地区影响 ANM 工作表现的因素。
在机构、地区、州和国家各级与 13 名精心挑选的主要信息提供者进行了半结构式访谈。与 41 名 ANM 和 25 名社区成员进行了焦点小组讨论。对 8 名 ANM 进行了非参与式观察，以提供信息来扩展和审查从其他调查途径得出的发现。应用现实主义视角来确定 ANM 的绩效是由于“机制”（培训、监督、问责机制）在特定“背景”（监管系统、基础设施和资源、ANM 扩大的工作范围、性别角色和规范）下产生的。
监管系统执行不力导致培训机构培训质量标准参差不齐。在卫生系统等级结构内对 ANM 进行内部问责机制的挑战，使得难以确保个人问责制。所接受的培训和监督不足以应对当前的职责。监督方法侧重于将定期报告中的信息与预期产出进行比较。工作场所的临床支持不足，很少能发现和解决问题。
仅关注 ANM 的任务并提供技术投入不足以在不断变化的背景下充分发挥 ANM 的潜力。系统地努力解决影响 ANM 工作场所的因素，可以培养出一支有用的干部队伍，在印度实现全民健康覆盖方面发挥重要作用。
