Pregnancy is a special event not only in the life of women but also to the entire family. Pregnancy is one of the wonderful and noble services imposed by nature. This experience of transformation from womanhood or wifehood into motherhood is a privilege reserved exclusively for women. Hence this transformation phase that is pregnancy and following childbirth has been contributed to have a great impact on both maternal and infant health.
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In any community, mother and children constitute a priority group, they comprise approximately 71.14% of the population of the developing countries. In India women of the childbearing age constitute 22.2% and children under 15 years of age about 35.3% of the total population, together they constitute nearly 57.5% of the total population. Mother and children not only constitute a large group but they are also a vulnerable or special risk group.
Since 1951, on voluntary basis with democratic manner, the Government of India, Ministry of Health and Family Welfare, has implemented different types of programmes for the improvement of maternal and child health and family welfare. In light of the Millennium Development Goals (MDG), National Population Policy (NPP), and National Health Policy (NHP), the Government of India, Ministry of Health and Family Welfare planned and launched National Rural Health Mission (NRHM) in April 2005 for the benefit of maternal and child health. All the efforts under NRHM are directly and indirectly aimed to provide accessible, affordable, and effective healthcare to all citizens and particularly to the poor and vulnerable sections of the society andbridging the gap in rural health care through creation of a cadre of accredited Social Health Activist (ASHA).
According to the needs, experiences and feedbacks, various changes and modifications have been incorporated from time to time. Several new approaches, interventions, and alternatives were initiated to reduce maternal child morbidity, mortality ratio like Maternal and Child Health (MCH), Child Survival and Safe Motherhood (CSSM), Universal Immunisation Programmes (UIP), Oral Rehydration Solution (ORS), Dais’ training, Medical Termination of Pregnancy (MTP), Postpartum Programmes, National Maternal Benefit Scheme (NMBS).
Most women may not have any problems during pregnancy, but some face problems related to pregnancy and child birth. The slogan for World Health Day 2005 was “Makeevery mother and child count,” reflects the reality that today, Government and the International community needs to make the health of the women and children the top priority.
The Maternity Benefit Act has been in existence for over five decades. The vast majority of Indian women do not get any maternity entitlements as the legislation does not apply to the unorganised sector. The majority of working women in the country work until the end of pregnancy and get back to work soon after delivery to avoid loss of wages. In response to long standing demand for the utilization of maternity benefit the Government of India has finally come up with a scheme that promotes the health and nutritional status of pregnant and lactating women and for the infants.
Maternity Benefit schemes are a provision for the payment to pregnant women belonging to poor households for perinatal care upto first two live births. The benefit is provided to eligible women of 19 years and above.
Some of the maternal benefit schemes are Dr.Muthulaskhmi Reddy Scheme, Janani Suraskha Yojana, Vandemataram Scheme, Family Planning Scheme and Two Girl Child Protection Scheme has been implementing in the present scenario.
BACKGROUND OF THE STUDY:
Maternal mortality is not just a health issue; it is a human right issue. Maternal mortality is one of the public health indicator showing the maximum variation between developed and developing countries.
Each year in India, roughly 30 million women experience pregnancy and 27 million have a live birth. Of these, an estimated 1, 36,000 maternal deaths and one million new born deaths occur each year. Thus pregnancy-related mortality and morbidity continues to take a huge toll on the lives of Indian women and their new born. These considerations have led to the formulation of specific health services for mother and child in India.
The World Health Organization (WHO) estimates show that of 536,000 maternal deaths occurring globally each year, 136,000 take place in India. The status of women is generally low in India, except in the southern and eastern states. Female literacy is only 54% and women lack the empowerment to take decisions including decision to use reproductive health services. As the health care services are governed at the state level much also depends on the state leadership and management skills. Antenatal care for pregnant women is one of the important factor in reducing maternal morbidity and mortality. Essential obstetric care intends to provide the basic maternity services to all pregnant women through early registration of pregnancy (within 12-16 weeks), provision of minimum three antenatal checkups by medical officer to monitor progress of the pregnancy and to detect any risk /complication so that appropriate care including referral could be taken in time, provision of safe delivery in an institution provision of three postnatal checkups to monitor the postnatal recovery and to detect complications.
Janani Suraksha Yojana is an ambitious step under National Rural Health Mission which is introduced on 12th April 2005 to reduce maternal and neonatal mortality by promoting institutional deliveries as well as better antenatal care and postnatal care for mothers in below poverty line. Institutional deliveries will not only facilitate safe delivery but will also identify neonates who need special care. The safe delivery process conducted in an institution will have a definite impact on reduction of maternal mortality.
Janani Suraksha Yojana, under the overall umbrella of National Rural Health Mission (NRHM), has been proposed by a way of modifying the National Maternity Benefit Scheme (NMBS). While NMBS is linked to the provision of better diet for pregnant women from Below Poverty Line (BPL) families, Janani Suraksha Yojana integrates cash assistance with antenatal care during the pregnancy period, institutional care during delivery and immediate postpartum period in a health centre by establishing systems of co-ordinated care by the field level health workers. The Janani Suraksha Yojana is 100 percent centrally sponsored scheme launched by the Honourable Prime Minister of our country on April 12, 2005 for reducing maternal and neonatal mortality.
Vandemataram Scheme is a voluntary scheme where in any Obstetric and Gynaecologist specialist, maternity home, lady doctor/MBBS doctor can volunteer themselves for providing safe motherhood services. The enrolled doctor will display vandemataram logo at their clinic. Iron and Folic acid tablets, oral pills and Tetanus Toxiod injections, will be provided to the doctors for free distribution to beneficiaries who have vandemataram cards.
Dr.Muthulakshmi Reddy Maternity Benefit scheme provides Rs.12,000 to pregnant mothers residing inTamilnadu. Its objectives are to prevent maternal and infant deaths, to make use of health care services, given only for first two deliveries.
In urban areas more than 69% of deliveries take place in institution, but in rural areas only 30% of deliveries take place in institution. Delivery of a newborn in an institution also provides an opportunity to the health care system to administer immunization at birth.
Immunization of a newborn with BCG vaccine enhances the efficacy of the vaccine by avoiding the interference with atypical mycobacterium which can infect the child during the post neonatal period. Likewise, administration of “0 dose” of OPV leads to early colonization of the intestinal tract with the attenuated vaccine virus which can act as a barrier to the wild polio virus. At birth immunizationis an important preventive measure however the impact of Janani Suraksha Yojana scheme on at birth immunization practice especially in tertiary level health centre has not yet been documented.
NEED FOR THE STUDY:
Every pregnant woman hopes for a healthy baby and an uncomplicated pregnancy. However, every day, about 1,500 women and adolescent girls die from problems related to pregnancy and childbirth. Every year, some 10 million women and adolescent girls experience complications during pregnancy, many of which leave them and/or their children with infections and severe disabilities.
According to WHO global estimate is 5, 00,000 women die every year and in that 1,500 women die in a day because of complications of pregnancy and childbirth. Each year, approximately eight million women suffer frompregnancy-related complications and over half- a- million die. Some 99 per cent of all maternal deaths occur in developing countries. Two thirds of maternal deaths in 2000 occurred in 13 of the world’s poorest countries. During the same year, India alone accounted for one quarter of all maternal deaths.
Pregnant women die in India due to a combination of important and preventable factors like, poverty, ineffective or unaffordable health services, and lack of political, managerial and administrative Will. All this culminates in a high proportion of home deliveries by unskilled relatives and delays in seeking care and this in turn adds to the maternal mortality ratios. The institutional delivery or delivery by skilled personnel plays a major role in reducing MMR and IMR. In India, while 77% of pregnant women receive some form of antenatal check-up, whereasonly 41% deliver in an institution. Even though all services are free, only 13% of the lowest income quintile delivers in a hospital.
Gupta R. K. (2005) conducted a cross-sectional study to determine the performance of institutional and non-institutional deliveries among 400 households in the slums of Delhi. The economic status was identified as the one for preference for non-institutional deliveries. The researcher further concluded that improvement in the financial support of the people may promote institutional deliveries.
Maternal Benefit Schemes provided by the Government help to improve the health status of the women by financial support. Still the utilization rate of the government maternity benefit schemes in rural and urban population is only 77%. Investigator found that the possible causes for not utilizing of such scheme may include assumption of better services in private or lack of awareness regarding the schemes. Creating awareness to these groups of people could be achieved through the doctors and nurses working in private sectors. Hence the investigator felt the need to assess the knowledge regarding maternal benefit schemes among nurses and doctors working in private hospitals who can create awareness and refer the under privileged group to the government maternity centres.
STATEMENT OF THE PROBLEM:
A study to assess the knowledge regarding various maternal benefit schemes available for our population among the health care personnel in selected settings in Chennai.
OBJECTIVES OF THE STUDY:
To assess the level of knowledge of health care personnel regarding various maternal benefit schemes available for our population.
To assess the source of information regarding various maternal benefit schemes available for our population.
To compare the level of knowledge regarding various maternal benefit schemes between doctors and nurses.
To associate the level of knowledge regarding various maternal benefit schemes with the demographic variables.
To associate the level of knowledge regarding various maternal benefit schemes with the source of information.
ASSESS: It refers to an act of gathering information by using structured questionnaire from the health care personnel about maternal benefit schemes.
KNOWLEDGE: It refers to Health care personnel’s awareness regarding maternal benefit scheme.
VARIOUS MATERNAL BENEFIT SCHEMES: It refers to more than one special maternity benefit (cash assistance) provided by the Government for the pregnant women for regular checkups, institutional delivery and postnatal mother to have a healthy life and safe delivery, to have basic immunization to the child and use of family planning services.
POPULATION: It refers to all women eligible to avail the maternal benefit schemes living in Tamilnadu.
HEALTH CARE PERSONNEL: It refers to doctors of any speciality and nurses who work in private hospitals.
The knowledge about the maternal benefit schemes may vary from one health care personnel to the other.
The knowledge about the maternal benefit schemes will be influenced by the demographic variable.
Study is limited to a period of 4 weeks of data collection.
The finding will reveal the existing knowledge on maternal benefit schemes among health care personnel working in the private hospitals.
Conceptual framework represents a less formal attempt at organizing phenomena than theories. It refers to concepts that structure or offers a framework of prepositions for conducting research. Polit and Hungler (1989) describes conceptual framework as “a group of mental images or concepts that are related but the relationship is not explicit.” The conceptual framework gives the idea to the researcher’s main view and common theme of the research that is a visual diagram by which the researcher explains the specific area of interest.
The conceptual framework adopted for the study was based on “Rosenstoch’s Health Belief Model (1974)”. This model intended to predict which individual would or would not use such preventive measures as screening for early detection of disease.
The health belief model focuses on the aspects of
Likelihood of action
Individual perception: In this study the individual perception is the health care personnel’s perception of their knowledge of various Maternal Benefit Schemes available for our population in the below poverty line group.
Modifying factor: The modifying factor in this study are the demographic variable such as age, sex, educational qualification and work experience.
The cues to action: The cues to action in this study are the basic training, refers to knowledge gained by basic training, experience, information from other health worker, internet, books, newspaper, and also training programme attended.
Likelihood of action: The likelihood of action of health care personnel had been recommended for further in service education and training programme regarding various Maternal Benefit Schemes available for our population. The Like hood of action is based on the level of knowledge for samples with excellent and good knowledge recommendation to plan for reinforcement was given and for samples with poor and average knowledge further training programme was recommended.
LIKELIHOOD OF ACTION
KNOWLEDGE OF HEALTH CARE PERSONNEL REGARDING VARIOUS MATERNAL BENEFIT SCHEMES AVAILABLE FOR OUR POPULATION
YEAR OF EXPERIENCE
ELICITING THE KNOWLEDGE OF THE HEALTH CARE PERSONNEL REGARDING VARIOUS MATERNAL BENEFIT SCHEMES AVAILABLE FOR OUR POPULATION
OUR POPULATION AMONG HEALTH CARE PERSONNEL. OF THE MIDWIVES ON FIRST AID MANAGEMENT OF SELECTED OBSTETRICAL EMERGENCIES IN PERINATAL PERIOD
EXCELLENT KNOWLEDGEEE KKNOWLEDGE
RECOMMENDED FURTHER TRAINING PROGRAMME FOR HEALTH CARE PERSONNEL.
CUES TO ACTION:
BASIC TRAINING [ MBBS, PG, GNM,BSc,MSc. N]
KNOWLEDGE GAINED BY EXPERIENCE
INFORMATION OBTAINED FROM OTHER HEALTH WORKERS, MASS MEDIA, NEWSPAPER, BOOKS & INTERNET.
ATTENDING TRAINING PROGRAMMES
13Fig: 1 CONCEPTUAL FRAMEWORK BASED ON THE ROSENSTOCH’S HEALTH BELIEF MODEL (1974)
REVIEW OF LITERATURE
Literature review aids in familiarizing the researcher within the context of the existing knowledge which has been gained from earlier studies which forms the integral part of search before dealing into the actual process of a study, interpreting the results of the study and making judgement about application of new knowledge in nursing practice.
This chapter presents the review of literature under the following headings;
PART I. General Information regarding Maternal Benefit Schemes.
PART II. Studies related to Maternal Benefit Schemes.
PART I: GENERAL INFORMATION ABOUT MATERNAL BENEFIT SCHEMES.
There is a provision for the payment per pregnancy to women belonging to poor households for pre-natal and postnatal maternity care up to first two live births. The benefit is provided to eligible women of 19 years and above.
Dr. Muthulakshmi Reddy Maternity Benefit Scheme fund is enhanced to Rs.12,000/-. The cash assistance will be given in three instalments (Rs.4000) on conditional release and restricted for first two deliveries only. The pregnant mother should be of age 19 years and above, the pregnant women should be in the below poverty line group. This cash assistance will be given to every pregnant woman who avails all required antenatal services during pregnancy in concerned PHC, mother who delivers in the government institutions (Primary Health Care, Government Hospital and Government Teaching institutions), completes immunization for the child up to 3rd dose of DPT (Pentavalent/Hepatitis B/Polio).
Janai Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NRHM) being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among the poor pregnant women. The Yojana launched on 12th April 2005 is being implemented in all states.
The Girl Child Protection Scheme is aimed at preventing gender discrimination by empowering and protecting the rights of girl children through direct investment from government. The Girl Child Protection Scheme enhance the status of girl child and promotes adoption of small family norm by ensuring holistic development of the girl child for a bright future entailing improved sex ratio besides preventing female infanticide.
The scheme aims to :-
promote enrolment and retention of the girl child in school and to ensure her education at least upto intermediate level.
encourage adoption of family planning norm with two girl children.
protect the right of the girl child and provide social and financial empowerment to girl child.
eliminate negative cultural attitudes and practices against girls.
strengthen the role of the family in improving the status of the girl child.
extend a special dispensation to orphans/destitute and differently abled girls.
Family Planning Scheme – The use of incentives to encourage couple to practice family planning has become a common strategy in many developing countries. Financialcompensation to individuals undergoing sterilization was first introduced in 1966. Over the years, it has been gradually increased. Women acceptor now receives onetime payment of Rs.750/, and men acceptor receives Rs.1,100. This is applicable for people below poverty line and those from scheduled caste and scheduled tribes.
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Vandemataram Scheme is a voluntary scheme where in any Obstetrics and Gynaecology specialist, Maternity Home, Nursing Home, lady doctor/MBBS doctor can volunteer themselves for providing safe motherhood services. The enrolled doctors will display ‘Vandemataram logo’ in their clinic. Iron and Folic acid tablets, oral pills and TetanusToxid injections etc, will be provided by the respective district medical officer to the Vandemataram doctors/clinics for free distribution to beneficiaries.
The above content helps in understanding the various Maternal Benefit Schemes available for our population and also acts as basis for tool formulation.
STUDIES RELATED TO MATERNAL BENEFIT SCHEMES
Sohail Agha (2011) found only 39 percent of deliveries in Pakistan are attended by skilled birth attendants, while Pakistan’s target for skilled birth attendant by 2015 is more than 90 percent. A strong outreach model was used and voucher booklets valued at Rs.50, and found purchase of a voucher booklet was associated with a 22 percent point increase in antenatal care use, a 22 percent point increase in institutional delivery and a 35 percent point increase in postnatal care use.
Sanjeev K. Gupta (2011) conducted a descriptive study to assess the social profile knowledge, attitude and utilization pattern of Janani Suresh Yojana beneficiaries in N.S.C.B.Medical College, Jabalpur during 2007-2008 with a sample size of 300 beneficiaries.77.66 percent belong to below poverty line (BPL) category, 67 percent of the respondents arranged their own / hired vehicle for transportation for delivery and 17.33 percent were motivated by ANM/ DAI/ ASHA/ AWW for institutional delivery. In many cases the husbands decided the purpose for which money was to be used.
Parul Sharma (2010- 2011) conducted a study to find out the difference in utilization of Janani Suraksha Yojana in rural areas and urban slums and reported that out of 227 cases registered with ASHA a maximum number (83.64%) of those women belonged to urban slums; 48.31% women consumed hundred Iron Folic Acid tablets and the proportion was high in rural women. All the women received complete Tetanus Toxid immunization. The Janani Suraksha Yojana was found to be low in rural areas (i.e.) 38.7 percent. Thus, Information Education Communication activities should be strengthened and ASHA’S work should be properly monitored.
Stephen S L. (2010) had done a nationwide district-level household survey in 2002-04 and 2007-09 to assess the effect of Janani Suraksha Yojana on intervention coverage and health outcomes. Findings showthat theimplementation of Janani Suraksha Yojana in 2007-08 was highly variable by state, from less than 5% to 44% of women giving birth receiving cash payments from Janani Suraksha Yojana. The poorest and least educated women did not always have the highest odds of receiving Janani Suraksha Yojana payments. Janani Suraksha Yojana had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, Janani Suraksha Yojana payment was associated with a reduction of 3.7 perinatal deaths per 1000 pregnancies, 2.3 neonatal deaths per 1000 live births, and 4.1 perinatal deaths per 1000 pregnancies. The findings of this assessment are encouraging, but they also emphasize the need for improved targeting of the poorest women and attention to quality Obstetric care in health facilities
Kranti S.Vora (2009 ), in this study he reported that India’s goal is to lower maternal mortality to less than 100 per 100,000 live births but that is still far away . It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence based effective monitoring for rapid progress.It stressed the need for regulation of the private partnership and polices, along with astrong political Will and improved management capacity for improving maternal health.
Shared D. Iyengar, (2009) in his study on persistence of poor maternal health in Rajasthan a large state of North India states thatthe rate of reduction in Rajasthan’s maternal mortality ratio (MMR) has been slow and it has remained at 445 per 1000 live births in 2003 and 32% of women delivered in institutions in 2005-2006. The recent scheme of Janani SurakshaYojana provides an opportunity to improve maternal and neonatal health.
Vaishali (2009) conducted a study to evaluate the utilisation of Janani Suraksha Yojana among the 100 beneficiaries in Orissa. Beneficiaries were selected randomly through Probability Proportionate to Sample size (PPS). The results revealed that major advantages of the Janani Suraksha Yojana perceived by the beneficiaries were safe delivery at PHCs and CHCs, helpful in population control, payment of cheque after delivery and full protection after delivery. Hence it was conclude that Janani Suraksha Yojana is a safe motherhood intervention for the health and welfare of the mothers.
Sharma MP.Soni SC. (2009) conducted a study to assess the gaps in delivery services and utilization of resources at Basic and Comprehensive Emergency Obstetric Care Centres, accredited sub centres and private hospitals in district Jaipur, Rajasthan.Result shows that there was an increase in institutional deliveries following implementation of Janani Suraksha Yojana.The quality of emergency obstetric care services was still poor due to the lack of blood storage units and anaesthetists in CEMOCs. Private accredited hospitals fared better as they had the manpower and managed more complicated cases as compared to government facilities. The study concludes that Janani Suraksha Yojana is perceived as an effective scheme by the beneficiaries but gaps in resources and lack of quality of services needs to be adequately dealt.
Thansia K.Seemanth (2009) conducted a study to assess and evaluate the operational mechanism, utilization, non-utilization, awareness and perception of mothers about Janani Suraksha Yojana in two blocks each district of South Orissa. The study revealed that there was a lack of orientation of the health staff other than ASHA on Janani SurakshaYojana. ASHA played a major role in motivating institutional deliveries in two third of the utilizers, most of the utilizers expressed problem of communication and transport. The study recommends for streamlining of fund flow, accreditation of private hospitals, and intensification of Information Education Communication activist, community leaders and women group for utilization of Janani Suraksha Yojana benefits.
Sharma R. (2008) had assessed the effectiveness of Janani Suraksha Yojana among 200 beneficiaries in the selected districts of Rajasthan. The results revealed that 178 beneficiaries received payment in cash and 22 by cheque and home deliveries were decreased. Overall status of ANC and PNC services also increased. 72% of the beneficiaries were registered within three months, received three ANC check-ups, used Iron Folic Acid tablets, postnatal check-up, received cash amount, and ASHA was with them at the time of delivery. It concludes that 70% of the beneficiaries were pre-aware about at least one of the aims and vision of Janani Suraksha Yojana.
Teenashu (2008) conducted a study to review the implementation process of Janani Surakaha Yojana in the state and to provide inputs for any corrective action in the three districts of Orissa. The study revealed that at the district, block and sub-centre level there was a shortage of medical and paramedical staff and inadequate facilities for institutional delivery. Hence, the investigator concludes with two major recommendations: (i) strengthening of infrastructure, supplies and human resources at all levels under the Janai Suraksha Yojana, and (ii) Streamlining the fund flow mechanism at two levels immediate compensation to the beneficiary after the delivery and regular payments/salaries to the ASHA.
The above mentioned studies help in giving an overview regarding the schemes how it has been utilized, implemented, status of institutional delivery and the knowledge of the beneficiaries. This shows that efforts are taken at the Government institution to improve perinatal services and the present utilization status.
This study was undertaken to assess the knowledge regarding various maternal benefit schemes.
This chapter on methodology includes research approach, research design, setting, population, criteria for selection of sample, sample size, sampling technique, data collection tool, development and description of the tool, data collection procedure and plan for data analysis.
Research approach was evaluative in nature.
Research design was descriptive in nature.
SETTING OF THE STUDY:
Voluntary Health Services Multispecialty Hospital, Adyar, Chennai.
C .S. I. Kalyani Multispecialty Hospital, Mylapore, Chennai.
POPULATION OF THE STUDY:
The population of the study consisted of both Doctors and Nurses belonging to different speciality with varied experience working in the above mentioned hospitals, in Chennai.
Doctors and nurses who fulfilled the inclusion criteria.
CRITERIA FOR THE SELECTION OF SAMPLE:
Doctors belonging to all specialities and working in the selected hospital.
Nurses working in all areas /wards in selected settings.
Samples who were not interested to participate.
Samples who were not on duty.
Samples of pilot study were excluded.
SAMPLE SIZE :
The sample size for this study was 60 health care personnel which include 30 doctors, 15 from each setting and 30 nurses, 15 samples from each setting.
The sampling technique used in this study was Non probability convenient sampling.
DATA COLLECTION TOOL:
The data was collected from the Health Care personnel using Structured Questionnaire.
DESCRIPTION OF THE DATA COLLECTION TOOL:
The tool prepared in this study was based on the information gathered from review of literature, objectives of the study and the personal and professional experience of the investigator. It consisted of two parts:
Part I: It consisted of questions to assess the demographic variables of Doctors and Nurses like age, gender, educational status and work experience.
Part II: It consisted of questions to assess the knowledge on the maternity benefit schemes, objectives, purposes, cash amount, eligibility criteria, and scheme when started and how they came to know about the schemes.
PART II- To assess the knowledge regarding maternal benefit scheme among health care personnel, there are 15 questions with 5 options. There are appropriate options and inappropriate options.
For each appropriate option when selected as score of 1 will be given.
For each inappropriate option when a selected a score of 0 will be given.
Certain questions has one right answer, some have four and five right answer also.
The total score is 25 and the score obtained is converted into percentage and graded as follows.
More than 81% —- Excellent
61%—-80% —- Good
41%—60% —- Average
Less than 40% —- Poor
VALIDITY OF THE TOOL
The tool used in the study was validated by experts from the field of Obstetrics and Gynaecological Nursing and Obstetrics and Gynaecology.
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