Hrev_master [page 40] [Healthcare in Low-resource Settings 2013; 1:e10] The cutting edge in the blunt space: an anthropological construct of auxiliary nurse midwives’ social world in the community Avanish Kumar,1 Meerambika Mahapatro2 1Management Development Institute, Gurgaon; 2National Institute of Health and Family Welfare, New Delhi, India Abstract Auxiliary nurse midwives (ANMs) are the most peripheral health providers and manage the rural health sub-centre in a community. They mediate directly between the community and the health system for the management of Maternal and Child Health Programme in India. The purpose of this study was to find out the role of cultural factors, such as ANMs’ caste, age, marital status, being non-resident in the working village and other social factors regarding their acceptance in the community. The study is exploratory and qualitative. The area of study was a multi-caste remote village, Mavaibhachan, in Kanpur Dehat district of Uttar Pradesh, India. Data were collected through in-depth interviews and fieldwork notes taken during and immediately after the interviews with ANMs, and thematically ana- lyzed. Our results show that if ANMs belong to a different caste group, do not live in the work- ing village and are relatively younger, they are socially insecure and stressed and the commu- nity hardly accepts them. Despite direct inter- face with the community, their social status and lowest position in the health system is reflected in acceptability and recognition. The position of ANMs needs to be strengthened, within society and the health system. In order to make public health services effective and efficient the health system has to reduce strat- ification based on role and status. Introduction Auxiliary nurse midwives (ANMs) are the most peripheral health providers, and as a per- manent functionary of health system, they manage the rural health sub-centre (SC) in a three-layered health system, interact directly with the community thus managing the Maternal and Child Health Programme in India.1 Considering their status as front-line or cutting-edge, grass-root level health providers in the health organizational hierarchy, and the gamut of functions performed, their work is fundamental to the success of the health pro- gram.2 Recent policy shifts in National Rural Health Mission (NRHM) have made it clear how it is ANMs’ responsibility3 to manage all aspects of health and family welfare.4,5 Other tasks include performing national health pro- grammes and support the International Classification of Diseases (ICD) and other out- of-reach governmental services.6 Consequent to the multiple functions performed by ANMs, they are expected to do home visits to meet the health needs of every household in the com- munity, especially the poor and vulnerable sec- tions of population in rural areas.7,8 They attempt to be on regular contact with their area population both individually and collec- tively and cover the area on foot, which often extends to socially and spatially excluded com- munities. With their active work and involvement in the community, they are expected to provide quality and timely health care. The limited time spent by workers in their jobs is a central factor in low levels of outreach effort.9-11 Auxiliary nurse midwives are expected to live in the SC village and be available around the clock for providing their service.12,13 Of the 20,521 SCs in Uttar Pradesh, India (September 2005), 32% had ANM quarters moslty inhabit- ed by ANMs (5,183 out of 6,494). Yet, given that two-thirds of the SCs did not have staff quarters, it would be hardly surprising if ANMs rarely showed up for work.13,14 The role of ANMs has markedly changed over the past four decades,15 however, their training and infra- structure support remains stagnant. The efficiency and effectiveness of ANMs is more complex because their area of operation is embedded with social-political dimensions. A bigger problem lies in the increasing demand, diminishing resources and less atten- tion paid to systemic operational problems that limit the functioning of services.8,12 This fur- ther gets accentuated because many ANMs have to face the consequence of such a mech- anism of inefficiency allocation, chronically absence of human resources and doctors, and patients who are routinely charged for some services meant to be free.9,10 Unlike hospitals or clinics, in villages, their gender, caste and even age, rather than disease and medicine, do influence consumers’ decision on health serv- ices.16 Auxiliary nurse midwives work with the people confronted with illiteracy, poverty, unemployment, deep-rooted social customs and local caste-based politics. They have to provide services where people lack health cul- ture.17 Here, the clinical practice of medicine is not an idealized application of literacy and declarative system of knowledge learned in basic science courses, medical clerkships and practice, but like any other exchange, it is an arena for constructing new schemata by intu- itively and systematic analogically modifying old domains of knowledge that interact with new experiences embedded in often mundane, emergent settings.18 The effect of these social factors in their routine work and acceptance in the village goes unnoticed.19 A prolonged non-response to emotional and interpersonal stressors on the job has an implication on inefficacy. It also depends on auxiliary nurse midwives’ experi- ences revolving around the quality of their relationship with the community, social status, their position in the occupational hierarchy of the health services, the nature and location of their health work, and their support mecha- nisms (professional, infrastructural, and per- sonal). The present paper aims to find out how social factors like ANMs’ caste, age, marital status and being non-resident in the working village and other social factors contribute to their acceptance in the community, which in turn influences the quality of care rendered by ANMs. Materials and Methods The study design is exploratory and used a qualitative method. The participants’ observa- tion was carried out by staying in the village for six months. The area of study was Mavaibhachan, a multi-caste remote village in Kanpur Dehat district of Uttar Pradesh, India. During fieldwork, basic facilities such as elec- tricity and toilets were far to be reached from the village. Healthcare in Low-resource Settings 2013; volume 1:e10 Correspondence: Meerambika Mahapatro, National Institute of Health and Family Welfare, Baba Ganganath Marg, New Delhi, India. Tel. +91.011.2616.5959 - Fax: +91.011.2610.1623. E-mail: meerambika@rediffmail.com Key words: auxiliary nurse midwife, community, community health worker. Contributions: the authors contributed equally. Conflict of interests: the authors declare no potential conflict of interests. Received for publication: 8 January 2013. Revision received: 17 January 2013. Accepted for publication: 2 February 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright A. Kumar and M. Mahapatro, 2013 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2013; 1:e10 doi:10.4081/hls.2013.e10 No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2013; 1:e10] [page 41] Study design and setting The study design is exploratory and used a qualitative method to capture the worldview of the ANMs. The area of study was a village called Mavaibhachan located in Ghatampur block in Kanpur Dehat (rural) district of Uttar Pradesh, India. As the name suggests, Kanpur Dehat is one of the most backward districts of Uttar Pradesh. Ghatampur block was purpo- sively selected as one of the most social-eco- nomically backward block, having poor health indicators and a multi-caste village. The two dominant caste groups are the religious supe- rior caste of Brahmins and the politically and economically dominant caste of Yadavs. The conflict between the two castes in local politics is reflected in their daily activities which fur- ther impact the health seeking behavior, as ANMs come from one dominant caste, i.e. Brahmin. The SC was located in a house of a Brahmin. Being a widow, her regular visit to the village was question on her character by the other caste groups. During our stay in the village for six months, we interviewed and observed the work space of ANMs of different villages of Ghatampur block, Uttar Pradesh. To triangulate our observations, we conducted in- depth interviews of 20 fellow ANMs working in the district. Sample size and frame Twenty ANMs of Ghatampur block were selected for in-depth interviews till data satu- ration. The method utilized was intensity sam- pling. Data collection Data were collected through in-depth inter- views. Quasi-non-participant observations were carried out to understand the interaction between community men and the ANMs. The questionnaire was open-ended and case narra- tion was recorded. The narratives from ques- tionnaire, field notes and diary were tran- scribed and thematically analyzed. Some of the important questions asked were i) how ANMs’ caste influences the routine work schedule; ii) whether ANMs’ age and stage (marital status) affect their work; iii) ANMs as outsiders or non-resident in the village; iv) ANMs’ assis- tance delivery, sex of the child, support (pro- fessional and interpersonal) mechanisms; v) ANMs’ training; etc. Informed consent was obtained from all participants: participation was entirely voluntary and confidentiality assured. Health administration and communi- ty members were informed about the purpose of study. Results In ANMs’ everyday life, their interactions with people and their social intercourse in relation to their environment, community, caste and gender as social actors interpret and give meaning to their professional world. The ANMs were young, inexperienced to this real- life work environment challenges because they joined the job just after the usual institute training. Unlike controlled environment in hospitals, in the community the ANMs’ med- ical efficacy is confronted with social con- straints. This is the more so because ANMs are women and work in a conservative patriarchal caste, and class and gender-based rigid social settings. Our analysis focuses first on the social structure, ANMs’ caste, assistance delivery and sex of the child, their training as health providers, and their professional and interper- sonal support within the healthcare system. Subsequent sections examine the political quality of their facilities, deficiencies in ANMs’ performance and the targets. Auxiliary nurse midwives’ caste In multi-caste villages of Kanpur Dehat – which have a patriarchal and caste-based social stratification system – ANMs are Brahmin (the upper caste group) and this con- stitutes a problem. In Mavaibhachan, inter- caste rivalry existed between the Yadavs (tra- ditionally involved in dairy-related occupation and politically dominant in the region, though lower in the caste hierarchy) and the Brahmins. As a consequence of political con- flict, cases of murder, retaliatory looting and house burning took place, which is reflected in daily interaction. Despite repeated efforts, ANMs are not able to overcome their caste bar- riers with their technical competence only. As a result, the efficiency of the system and the effectiveness of services get affected. Since the SC of the public health system is located in a rented house within the village, ANMs get support to house SC in a Brahmin’s family. Auxiliary nurse midwives are categorized more as a Brahmin rather than healthcare providers. Auxiliary nurse midwives in the field have to face various social risks. The expectation of the community in terms of ANMs as an ideal womanhood puts them in question. This is more so, because they alone have to visit regularly to the SC that is in Brahmins’ house. Few villagers do raise their eyebrows before ANMs as they visit the SC located in other families’ house. In order to build their case against ANMs, Yadav commu- nity maligns their character and credentials. Similarly, an ANM from a lower caste reported that she faced discrimination in a higher caste group where she was not allowed to touch peo- ple who sit in a chair and insulted her in vari- ous ways. Auxiliary nurse midwives as a cut- ting-edge health professionals working in SC as a last mile health infrastructure lose their efficacy in a closely-stratified community. Therefore, real-life clinic of ANMs is constant- ly mediated with cultural impediments and social infrastructure. The devolution of power and decentraliza- tion of public services have exposed ANMs to community politics and prejudices. Another kind of harassment occurred when elected leaders – sarpanch – demanded special servic- es at home in their village, but their requests were not met. Thus, they complained against ANMs or rated their performance as poor in the appraisal dossier, or asked for transfer ANMs from the village. The problem gets worse because in the current policy, the sarpacnh (elected village head) is to sign the yearly progress and performance of ANMs. Auxiliary nurse midwives’ assis- tance delivery and sex of the child The household level demand is destined to sons. ANMs and midwives reported that deliv- ery of a female child fetched them less reward which was often expressed in less token money: approximately Rs. 50/- (around 1$) for a female child, while Rs. 500 (10$) and dress as a gift for a male child. A repeated delivery of girl child by ANMs is often considered as bad hand or unlucky for the family. Therefore, ANMs are not called for delivery anymore in the village. In another case, a man from the village brought a lady with whom he had extra-marital relation for forceful abortion. When the ANM denied doing so, she was threatened with dire consequences. This forced her to abort the fetus without infrastructure and technical sup- port leading to further complications due to abortion. Sometimes, due to similar pressure, ANMs are forced to adopt illegal practices of sex selective abortion. Auxiliary nurse midwives as out- siders or non-resident The notion of outsider for ANMs by the com- munity exists in Uttar Pradesh. In Kanpur Dehat, ANMs being outsiders has a negative impact. Auxiliary nurse midwives spent a large part of their service attempting to establish amicable relations with largely unfamiliar communities. They also try to establish a strong, credible presence in the community because they are seldom posted in their native villages. While building relations with strangers, they face sexual abuse, tease and harassment. An extended conversation with opposite sex is often quoted by the villagers as a default in the role model of ANMs: they are looked upon and tagged by the villagers as hav- ing extra-marital affairs. Since ANMs’ work requires them to speak openly about contra- ceptives with men, they are viewed as women of loose morals. This negative social image and vulnerable status within the health system Article No n- co mm er cia l u se on ly [page 42] [Healthcare in Low-resource Settings 2013; 1:e10] makes them an easy prey to sexual harass- ment. All the ANMs reported that most of the vic- tims of molestation are the ANMs who are the outsiders from different districts. One block of Kanpur Dehat is infamous for criminality. Once, an ANM got molested and the news got printed in the Hindi newspaper (state edition). Her family got to know about it and the ANM was forced to continue the job for her liveli- hood because her wage had a high impact on the economic stability of her households. Over time, ANMs encounter numerous obstacles in their work but do not dare to contemplate a job switch. The fear is socialized in the ANMs com- munity and has a direct impact on the health program. Among the consequences, ANMs’ vis- its to their respective area become fewer, their staying in the block area rather than at the SC or in the village; even though they are on night duty and do not prefer to travel at night. Auxiliary nurse midwives report that they have numerous reasons for preferring not to live in their SCs as personal safety is a major con- cern, especially for unmarried women, who are most vulnerable to sexual harassment. Auxiliary nurse midwives’ training Most trained ANMs felt that too much infor- mation had been imparted in a too short time in a real-life clinic. They were trained on pro- viding public services, but seldom they were trained in communication and negotiation skills at the village. This fails to build trainees’ confidence, a vital asset in an unassisted health workplace which requires independent decision making. Moreover, their cloistered existence in the school does little to prepare them for work in unfamiliar, often uninviting, village communities. The threat of sexual harassment and abuse mars the careers of most ANMs, but trainees are not informed of their legal rights or channels of redress. In the end, ANMs learn their lessons of village-level health work not in training schools, but while negotiating the numerous hurdles they encounter in everyday real-life clinics. Professional and interpersonal support Auxiliary nurse midwives reported that they need professional support to help them carry out the tasks assigned to them particularly at a sub centre (SC) level where they are deprived of the re-assuring environment of a health site compared to the ANM posted in the primary healthcare (PHC). They also reported that, though transitory supportive supervision is given on technical guidance, they also need moral support and encouragement to handle the SC more confidently. The situation is high- ly unpalatable when ANMs visit the SC and its doors are locked. The SCs were usually located at the village periphery or outside the protection of the main village cluster. They were often dark and dingy, sometimes located in rented rooms or govern- ment made structures with lack of electricity and drinking water facilities, i.e. they were not adequately or uniformly equipped and also lacked this basic amenity. Their physical work- ing conditions fall far short of that ideal with essential equipment and supplies. The vac- cines and medicines are often supplied in respect to the requirements. As a result, com- munity people asked to visit in the next ses- sion tikka nehi hai (unavailability of dose) in some of the PHCs and SCs. The sessions are organized weekly and, in some areas, children are already late for their scheduled vaccina- tion. These inadequacies affected the ability of ANMs to work with any degree of confidence in the community. Besides being overburdened, ANMs cited the inadequacy of facilities, equip- ment, and medicine stocks. They also com- plained about the lack of proper accommoda- tion and inadequate transport facilities. Discussion The outcomes of clinical encounters in the social world were influenced by various social circumstances. Socio-demographic character- istic of patients, ANMs’ professional and social background, and the organization of practice settings appear to determine ANMs’ responses to patients’ complaints at least partially.14 The medical setting in the hospital creates condi- tions under which every modes of communica- tion and thinking initially take precedence over formal concerns with production of objec- tive medical knowledge.9, 20 Nonetheless, in the social world of care and cure, ANMs and patients may have different health perspec- tives and therapeutic agendas.21 The representation of lower castes (chiefly scheduled castes) and upper castes, as evi- denced by the caste variation among ANMs of different ages, has increased the acceptance. Another important variable which is related to but not dependent upon geographical location is the resources of the practitioner’s disposal.22 In the course of ANMs’ life, their everyday interactions with people and social intercourse in relation to their environment, community, caste and gender as social actors, interpret and give meaning to their professional world.7 This is not to say that all actions are thought out, which would imply a highly rational view of behavior. It does, however suggest that all actions, even the most routine and automatic, are subject to interpretation and scrutiny in the local reality.23 Young, unmarried or not having children ANMs were facing more prob- lem in the working and getting accepted in the village. Older age, personal characteristics, place and length of employment, and work schedule had an effect. This outcome of non- acceptance of ANMs may be a result of socio- cultural differences that may be a reflection of difficulties in the work condition.24,25 Negative conditions where the workload extensively exhaust individuals with little remuneration and reward can disrupt the qual- ity and quantity of service26 by making it a blunt edge. Rather than loading all desired activities on the ANMs under the pretext of integration, different types of health personnel should be provided for implementing a partic- ular task. There is a need to separate functions and skills that can be integrated in one person and those that require different types of skills and appropriate training.27 Improved infra- structure facilities available at the health cen- tre can increase the mobility and social assis- tance/help by increasing the value of their work station.28 Alternative systems may be arranged to meet socio-cultural adaptation for better acceptance of ANMs. Decrease identity and social status gap between doctors and ANMs may increase acceptance of ANMs in the community very well and may be seen as a first step in the establishment of a quality frame- work. These concerns have to be adequately emphasized in India’s public health system. However, this will have to be backed up by uni- formly available and accessible health institu- tions and practitioners. It became clear that it is not enough to confine integration to single programs. It must bring together programs with common strategies and resource require- ments such as technological, organizational and administrative. Finally, it must also build a shared evaluation and monitoring mecha- nisms of conceived linkages and objectives so that they may be revised if required.27,28 Conclusions With the increasing devolution of public serv- ices, the role of ANMs has become much more complex and significant. The current epistemo- logical characteristics of medical theory taught in the training centre cannot be manifested directly. The health system needs to build the capacity of ANMs of evolving medical specializa- tion and social diagnostic practices. Although the health program has been devolved upon a bottom-up approach, system and structure still remain top-down. Despite direct interface with the community, ANMs’ lowest status in the health system gets reflected in their acceptabil- ity and recognition. 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