Fragile Lives

FRONTLINE- Volume 24 - Issue 5 :: Mar. 10-23, 2007

By 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.

Kudos to frontline on picking up this issue...