Vol:24 Iss:05 URL: March 2007

http://www.flonnet.com/fl2405/stories/20070323001708900.htm

PUBLIC HEALTH

Fragile lives

T.K. RAJALAKSHMI

The fundamental causes leading to high maternal mortality are yet to be

addressed.

Mamta Bahelia, A tribal woman in Pathadeori village of Madhya Pradesh's

Seoni district. Weighing 52 kg into the eighth month of her pregnancy, she
continues to do laborious work.

ACCORDING to the Sample Registration Survey for 2001-03, around 78,050

pregnant women die in India every year. For every hundred thousand live births,
there are 301 maternal deaths, the survey says. According to the White Ribbon
Alliance of India (WRAI), a nationwide initiative that promotes safe motherhood,
there has been no significant decline in India's maternal mortality rate (MMR) since
the 1990s. Surveys of the causes of the high MMR show how inaccessible timely
medical attention still is to many pregnant women. An inadequate health care system,
lack of awareness, bad roads and, of course, poverty are some of the major factors
that come in the way of safe deliveries for pregnant women. Surveys have also found
that the maximum number of maternal deaths is recorded among the Scheduled
Castes, the Scheduled Tribes and Other Backward Classes.

Bimla of Duhiya village in Murar block of Madhya Pradesh's Gwalior district is an

Accredited Social Health Activist (ASHA). Madhya Pradesh is one of the 18
Empowered Action Group States covered under the National Rural Health Mission
(NRHM); it is one of the "low-performing" States in terms of institutional deliveries,
along with Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Chhattisgarh, Rajasthan,
Orissa and Jammu and Kashmir. As an ASHA, Bimla gets Rs.600 for every pregnant
woman she is able to take to a government hospital for delivery. Indeed, all she can
remember of her "training" is that she, and others like her, were told that they would
be paid if they took pregnant women to hospital.

But Bimla could not save the life of her own sister-in-law, Khiloni. The family says
she died because there was no trained "birth attendant" in the village and the
government hospital where they took her would not accept the case because it was
complicated.

Bimla's is a family of landless farm hands. Duhiya is a village of mainly Jatavs,

though there are a few landed, upper-caste families too. Only a kutccha road links
Duhiya to Gwalior city. Bimla does not seem fully aware of the provisions of the
Janani Suraksha Yojana (JSY), operational since April 12, 2005, under which
pregnant women get Rs.1,400 if they give birth in a government hospital and are also
compensated if they give birth at home or in accredited private hospitals. Only two
of the 25 women she took to a government hospital for delivery got paid under the
JSY. Her own payment is often not on time and she is not paid for conveyance any
way. She is supposed to serve a `population area' of 1,000, but she serves two
panchayat areas with a total population of 2,000. Sometimes, she says, Auxiliary
Nurse Midwives (ANMs) refuse even to "touch" pregnant women of lower castes, let
alone attending to their needs.

Vinita Kalra, an auxiliary nurse midwife, has been working for eight years in
Mamodhan village of Rajasthan's Dholpur district. In this photograph, making
a home visit for an antenatal check-up.

According to an activist from a rights organisation in Murar, there have been several
cases in Duhiya where pregnant women were turned away from the government
hospital and forced to spend small fortunes on treatment at private hospitals. "This
also means that the ASHA does not get paid," she said.

In an area where maternal mortality obviously needs more attention than it gets,
priorities sometimes seem strangely misplaced. The medical officer in charge of the
primary health centre (PHC) in Hastinapur town of Murar block, for instance, could
only think of the missing boundary wall at his PHC when asked what problems he
faced at work. The centre he runs has no blood bank or ambulance services, no
female doctors, and its nurses are not trained in Emergency Obstetric Care Services
(EmOC). It has a proper building but is understaffed. Local people say there is no
one at the centre after evening though it has been converted into a 24-hour First
Referral Unit under the NRHM.

He denied that there had been any cases of maternal mortality at his PHC. But he
added that the families of pregnant women were usually to blame for pregnancy-
related deaths because they did not organise timely medical attention. By the time a
pregnant woman was taken to a doctor, he said, it was usually too late. He also said
that anaemia was a major cause of maternal mortality. At least on this last point, the
National Family Health Survey III would agree with him. The survey data, released
recently, show that nearly 82.6 per cent of the children in the age group of six to 35
months are anaemic; 40.1 per cent of women have a body mass index (BMI) below
normal; 57.9 per cent of pregnant women and 57.6 per cent of women who were ever
married are anaemic.

The Economic Survey (2005-06) says the NRHM is the chief vehicle for making
good the promises made on health care in the National Common Minimum
Programme. Commenting on the implementation of the NRHM so far, WRAI
spokesperson Aparajita Gogoi said there was no arrangement for training midwives
under the Mission. Most ANMs are at present involved with family planning and
health care for children. Skilled assistance at childbirth is not easily available. Much
of what happens in communities and in the hospitals goes unreported and there is
little accountability for maternal deaths. Doctors are often not trained in emergency
obstetric care services and nurses and midwives are not encouraged to carry out life-
saving procedures. Gogoi also said that panchayats were entitled to Rs.5,000 from
the Health Department for emergency obstetric care services, but most of them were
not aware of it and did not use the money.

Lack of nutrition is also a problem. The Integrated Child Development Services

centre at Duhiya functions from the home of an Anganwadi worker. The only diet
supplement that children and pregnant and lactating mothers receive here is soya
puffs.
 EVEN A BASIC labour room like this one is not something women have easy
access to in rural India. The government now offers cash incentives to
encourage women to go to hospitals for delivery.

The story is the same everywhere. Banjara Ka Pura, also in Murar, is a village
dominated by Banjaras, a Scheduled Tribe. All families in the village are landless
and daily wages do not exceed Rs.40. The entire village should have been
categorised as Below Poverty Line, yet few residents hold BPL cards. Even the grain
allotted for the BPL category is not sold at BPL prices. There are young widows and
old destitute women in the village who are not covered under the Antyodaya scheme
for foodgrain entitlement. Expenditure on health leads to bondage in the village.

One woman, Lakshmi, narrated how her pregnant daughter-in-law died of

haemorrhage after a miscarriage because she did not get timely treatment. "We used
to take her in a bullock cart every day to the PHC. But the centre refused to admit
her. We spent Rs.800 on a jeep to bring her body back," she said. She added that the
entire family now worked as bonded labourers for the local temple priest, who had
lent them Rs.35,000. Lakshmi's second daughter-in-law was luckier; she delivered
her child in a tractor.

A recent Maternal and Perinatal Death Inquiry (MAPEDI) study by the United
Nations Children's Fund (UNICEF), in Guna and Shivpuri districts of Madhya
Pradesh and Purulia district in West Bengal, says most maternal deaths occur within
six to 24 hours of delivery, the immediate cause being hemorrhage. In most of the
cases surveyed, the women were found to be severely anaemic, and had been so from
adolescence.
The MAPEDI study, based on interviews with families that had lost pregnant
mothers, highlighted that the majority of the deaths were preventable and that people
would access services if they could. Financial constraints and bad roads are among
the factors that prevent pregnant women and their families from accessing medical
attention during and after pregnancy. The fact that trained nurses and midwives are
not available round the clock also pushes up maternal mortality.

In the Purulia study of nearly 106 maternal deaths, it was found that nearly 80 per
cent of the women had sought formal care at some point of their illness and nearly 46
per cent had sought formal care after complications arose. Among the reasons for not
seeking formal care, 23 per cent of the respondents (family members) felt that
transportation was a leading cause. While 16 per cent felt that the person herself did
not perceive she was sick enough, only a meagre 8 per cent felt that the problem
required traditional care. Nine per cent could not pay for transport, while 10 per cent
said transport was not available.

The study, presented by Sudha Balakrishan, indicated there was an awareness of the
need to seek health care, just as there was in Madhya Pradesh. But while most
respondents in Purulia could afford transport to hospitals and health centres, very
few in the Madhya Pradesh case study said they could do so.

Shahikala Nageshwar of Jawarkothi village in Seoni district belongs to a

Scheduled Caste. Pregnant and underweight (43 kg) at 19, she was taken to
hospital for her delivery on a bullock cart by a midwife.

Following the UNICEF study, the Government of West Bengal decided to review
every maternal death. It also issued an order making all maternity beds in
government hospitals free of cost. The problem is that despite heightened allocations
for health care, the Central government continues to view health care as important
"not only for reaping the demographic dividend, having a healthy productive
workforce and general welfare, but also for attaining the goal of population
stabilisation. Population stabilisation is proposed to be achieved by addressing issues
like that of child survival, safe motherhood and contraception" (Economic Survey
2006-2007). Health activists have increasingly begun to de-link the goals of
population stabilisation from MMR and infant mortality rate (IMR), the
government's approach remains much the same.

The NFHS-III interviewed 230,000 women in the 15-49 age group and men in the
15-54 age group. It found that 44.5 per cent of the women were married before the
age of 18. Jharkhand recorded most of the cases (61.2 per cent), followed by Bihar
(60.3 per cent) Andhra Pradesh (54.7 per cent) and Rajasthan (57.1 per cent); the
lowest numbers were reported from Himachal Pradesh (12.3 per cent), Jammu and
Kashmir (14 per cent), Kerala (15.4 per cent) and Punjab (19.4 per cent).

There seems to have been a shift from a vertical approach to health care to a more
decentralised one and the 2007-08 Budget proposals include higher allocations for
health care. But there needs to be a greater emphasis on an inter-sectoral approach,
especially on food security. It is not only a question of meeting the Millennium
Development Goals any more, it is about being accountable and sensitive to the
needs of one half of the nation's population.