By Nupur Sonar:
Having a baby in a remote village of eastern Bihar, India means being pregnant with anxiety and a sense of helplessness. Without access to health infrastructure to monitor pregnancies and provisions for emergency care, it is a life threatening situation for both the mother and the unborn child. In cases of abortions, women who approach state-run health facilities are turned away due to lack of infrastructure and are forced to approach private practitioners. Most of them, cannot afford their services.
Last year, 24-year old Masuhsun Khatun from Fulvari village of Bihar’s Kishanganj district was expecting her fifth baby. She was five months pregnant in June 2014, when she tripped and fell in the front yard of her house.
Later that night, Masuhun woke up writhing in pain and bleeding profusely. Her husband tried calling a government ambulance but to no avail. He then hired a private vehicle to get Masuhun to the nearest government hospital. They found no doctors there and Masuhun was taken to a private practitioner, who informed her that she needed to undergo an abortion.
Two weeks after the abortion at a private health facility, Masuhun started bleeding again. This time she was taken to a state-run hospital, where she was told she had foetal remains in her womb. Masuhun was forced to undergo a remedial procedure at her home, under the supervision of an auxiliary nurse midwife (ANM), because the hospital lacked adequate medical facilities. Although, ANMs are not qualified to perform surgical procedures. Her condition worsened over the next five days before she passed away.
For three weeks, Masuhsun shuttled between private practitioners and state-run medical facilities. Her husband, a daily wage labourer, spent nearly Rs 40,000 on her pregnancy and the subsequent termination, including Rs 17,600 on eight bottles of blood required for transfusion.
Community Correspondent Navita Devi’s report reveals that due to lack of proper abortion facilities, trained medical personnel and access to public health facilities, several other women in Fulvari village of Kishanganj district in Bihar suffered the same fate as Masuhun’s. The ones who survived, live with financial burdens and a trauma that never leaves them.
This, however, isn’t just the story of the women of Fulvari.
India Has The Highest Number Of Maternal Deaths
56,000 women succumb to pregnancy related complications in India every year — the highest across the world. Rajasthan, followed by Assam, Uttar Pradesh and Uttarakhand, has the highest maternal mortality rates—the number of women aged 15-49 dying due to pregnancy related complications per 100,000 live births—in India, according to a report by the Registrar General of India.
Madhya Pradesh, Chhattisgarh, Odisha, Bihar and Jharkhand are other states with critical numbers. Infections due to non use of a sterile kit during delivery, home births without trained providers, eclampsia, postpartum haemorrhage, early pregnancies, anaemia and unsafe abortions are the leading causes of maternal deaths. However, these deaths are entirely preventable. According to government data, although India’s maternal mortality rate has come down considerably in the last two decades, urban-rural disparities continue to exist.
In 2005, the Ministry of Health and Family Welfare launched the Janani Suraksha Yojana (JSY), a cash transfer programme, that incentivised institutional deliveries, in order to reduce maternal deaths in India. Women are awarded Rs 1,400 in rural areas and Rs 1,000 in urban areas to give birth in public health facilities, under the scheme. It also makes provisions to reduce out-of-pocket expenditure, providing free antenatal check-ups, IFA tablets, medicines, nutrition in health institutions, provision for blood transfusion, and transport from health centres and back. The scheme, however, makes no provisions for medical intervention in cases of accidents, and women like Masuhusn are left to fend for themselves.
While the scheme’s focus remains on reducing maternal and neonatal deaths, by providing free institutional care, ground reports by Video Volunteers’ (VV) Community correspondents reveal that access to prenatal and postnatal care, nutrition and timely medical intervention remain dismal in several parts of the country.
These reports are first in a series of VV’s project on Community Monitoring of Maternal Health in India. Through its network of over 180 community journalists from marginalised communities, VV seeks to report violations, produce stories, take action and devise solutions to improve the state of maternal healthcare in India.
Women continue to give birth in deplorable conditions at unhygienic and ill-equipped health facilities. While Bharti Kumari reports on how dangerous it is to deliver at the Telmocho sub-health centre in Dhanbad district of Jharkhand, Meri Nisha Hansda’s report reveals how pregnant women wait for hours to receive medical attention and are charged not just for medicines but also for using the toilet at the Primary Health centre in Godda. According to the health ministry guidelines a Primary Health Centre is supposed to have two doctors. However, no doctor was present at the time when Paku Tudu was brought in to the hospital. Her delivery was conducted by an ANM.
Missing Infrastructure And Health Workers
While India’s public health system grapples with a dearth of health facilities, shortage of human resources is one of the biggest impediments to the functioning of existing public health facilities in India. The absence of a health centre nearby also means that pregnant women have to travel long distances to avail medical services.
In interviews to Reena Ramteke, several women from Khatti village in Chhattisgarh say that ANMs hardly ever visit the village, and that the sub-health centre in the village always remains locked. A sub-health centre is a state-run first care provider staffed by an ANM who is responsible for administering antenatal care to pregnant women.
One Frontline Health Worker For 14 Centers
Frontline health workers are often blamed for dismal healthcare in rural India. However, they are spread too thin and are forced to work under inhuman conditions. According to the ministry guidelines, one ANM is supposed to look after eight sub-health centres. However, in Jharkhand’s Dhanbad district, two ANMs look after 23 centres in Baghmara block. Ahilya Devi looks after 14 of the 23 centres. “There is no water and provisions for emergency light in cases of power failure. In such a case we have no choice but to use a flashlight, lantern or candle. How do we put stitches in such a case?” she asks. She admits that because of the workload, she often can’t make it to some sub-health centres.
Gyanti Kumari reports from Bihar’s Siwan district on the shortage of medicines at the Rajapur Primary-health centre and instances where women were forced to spend money on medical facilities they are entitled to under the JSY. “The ANM charged Rs 50 per injection and Rs 500 to cut my daughter’s umbilical cord,” says Muni Devi’s mother.
No Cash IncentivesInstances of women not receiving cash incentives promised under JSY are endemic across rural India. Satyanarayan Banchor, reports on one such instance from Bankheda village of Bolangir district in Odisha. “Why should we deliver at public health institutions when we neither get quality care nor incentives that we are entitled to?,” they ask.
Why Do Women Opt Out Of Government’s Scheme?
In testimonies to VV’s community correspondents, women say that the lack of infrastructure, support from healthcare providers and high out of pocket expenditure discourages them from seeking care at state-run facilities. Unavailability of or delay in the arrival of an ambulance is another deterrent.
In August this year, the health ministry plans to send voice messages delivering advice to pregnant women to increase health awareness amongst them. The government plans to make use of India’s network of 950 million mobile connections to combat maternal and infant mortality. This might prove to be a cost-effective way of spreading awareness but what about safety of women who choose to deliver at public health institutions? How far will awareness campaigns take us at a time when the public health system is in complete disarray?