Tackling maternal mortality in MP

By Rashme Sehgal

Shivpuri and Guna districts in Madhya Pradesh have one of the highest maternal mortality rates in India. But in a PHC in Satanvara block, two young doctors have ensured not a single maternal death in 257 deliveries they’ve handled over one year

The ravines of Chambal have given birth to many legends woven around the lives of notorious dacoits. One such legend is being woven around Ram Babu Gadaria, a shepherd by profession, who became a dacoit after his wife was raped by upper-caste landlords.

What has Gadaria got to do with the pressing issue of maternal mortality in a backward state like Madhya Pradesh? He has almost brought the tottering health system to a halt with his Phoolan Devi-like antics. He is said to kidnap doctors and health workers for ransom, releasing them after receiving hefty amounts from their families. Recently he kidnapped two private doctors with sizeable practises and released them after being paid astronomical sums of money.
Two young women doctors in their mid-20s, Manisha Yadav and Sandhya Gupta, working at a primary health centre (PHC) in the Satanvara block of Shivpuri district, adjacent to the Chambal valley, are terrified of Gadaria and his gun-toting gang. Both Manisha and Sandhya have been working at this PHC for over a year and have already handled more than 257 deliveries. But since many of these deliveries take place at night, these young women have to make their way from their rented accommodation to the PHC in the dead of night.
“It's very scary. Both of us have studied in Gwalior and the very thought of coming face-to-face with a member of this gang is alarming. The local villagers have told us that the Gadaria gang are quite active here,” said Manisha.

Both these doctors decided to accept this challenging assignment because they would receive a starting salary of Rs 15,000 per month. Salaries of doctors willing to accept field postings were recently hiked by the state government which realised that several PHCs and district hospitals were inadequately staffed. These two doctors claim credit for not having had a single maternal death so far. “Of the 257 deliveries we have conducted so far, we have not had a single maternal death,” they say.

The birth of two female children the night before by two tribal women has boosted their confidence further. Both the mothers and their babies are sleeping in a room adjacent to the makeshift operation theatre. One of the reasons for the absence of maternal deaths could be that caesarean and other complicated delivery cases are directed from here to the district hospital. “We have had three cases of stillborn babies. One case was of a mother running continuous high-grade fever giving birth to seven-month-old twins. Fortunately, the mother survived,” Manisha pointed out.

The district of Shivpuri, which falls in the Gwalior-Chambal zone, has one of the highest maternal mortality rates in India . A maternal death audit conducted by Unicef and local NGOs has brought to light that while 50 maternal deaths took place in Shivpuri in 2006, the figure in Guna district was 56. Guna is the parliamentary constituency of the high-profile Congress MP Jyotiraditya Scindia. The deaths were reported by the ANMs (auxiliary nurse midwives) and by local NGOs.

Dr Ramani Atkuri, of Unicef, Bhopal , pointed out, “This is the tip of the iceberg. We believe many more women have died from childbirth but their deaths go unreported.”
“The majority of deaths take place because of haemorrhage, severe anaemia, eclampsia, malaria and sepsis,” Atkuri added.

Internal bleeding, eclampsia and obstructed labour are just some of the factors that are responsible for the high number of maternal mortality deaths in Madhya Pradesh. Every five minutes, India suffers one maternal death. The number of women who die due to pregnancy, childbirth and abortion-related complications is estimated at 60,630. The maternal mortality ratio (MMR) for India presently is 301 deaths per 100,000 live births. Uttar Pradesh alone accounts for close to 21,450 maternal deaths per year.

The maternal audit also highlighted that less than 25% of babies born to women who died have a chance of surviving. This was borne out in Guna district. Ram Swarup Batham sits outside his mud hut in Shivpuri village surrounded by his three young children all below the age of five. His wife Veeja died recently in a hospital in Gwalior while giving birth to her ninth child.
Describing how he tried to save her, Batham says, “I rushed her to the district hospital in Shivpuri. The doctor there informed me she needed to be taken to Gwalior . I took her to Gwalior Medical College but she died soon after being admitted there.”

Batham, a tribal, is fortunate to own 25 bighas of land. “I borrowed Rs 15,000 for her treatment. I'll sell my land if I cannot repay the loan,” he adds. One RNTCP official says: “The lack of integration between the TB programme and the general healthcare system is the main reason why the programme has not attained its goals. The PHC health staff do not support the TB programme because it does not offer cash incentives. These vertical programmes are creating distortions, and there is no collaboration in the implementation of programmes.”
The death of his wife has plunged their family into chaos. For one, the entire responsibility of looking after the children has fallen on his aged mother who admits she simply cannot cope. Sitting on the mud-caked floor in their front courtyard, the old woman mutters, “The doctors were completely callous. Veeja died within five minutes of being given an injection.”

The tragedy of Veeja's death is that it could have been easily prevented. Hamid al-Bashir, Unicef's state representative in Bhopal , believes, “Most maternal deaths could be prevented if women had access to appropriate healthcare during pregnancy, childbirth and immediately after delivery. When a mother dies during pregnancy, the family suffers a further increase in poverty.”

“One of the key methods to improve maternal survival would be to review all maternal deaths at the community level,” al-Bashir adds. The official explains that the situation has been repeatedly highlighted before RNTCP officials in Delhi. “But,” he says, “they are avoiding the issue and tell us to try solving the problem locally.”

Dr Aparajita Gogoi, National Coordinator for the White Ribbon Alliance India , describes these MMR deaths as a “silent tsunami”. “Over 200,000 families have been devastated by these deaths which have left 350,000 kids orphaned. Another 600,000 women have been left disabled because of pregnancy-related disorders.”

Gogoi says, “We have not been able to stem this tide of maternal deaths despite having 20,000 obstetricians, 5 lakh trained doctors and 25 lakh nurses and midwives.” Even poor countries like Bangladesh , Bolivia and Honduras have reduced MMR in similar resource settings. Countries like China , Indonesia and Sri Lanka have built up teams of skilled birth attendants and well-connected frontline providers.

The statistics in Madhya Pradesh are more alarming because in rural areas, local NGOs point out, for every 5.6 villages (average population of 2,000 per village) only one hospital bed is available. Over 82% of the children suffer from anaemia while 58% of pregnant women are also found to be anaemic.

Unicef believes one of the ways to strengthen community initiatives is by holding maternal death audits. Another such audit was recently held in Purulia in West Bengal between May 2005 and June 2006. It was found that of 55,000 deliveries there were 106 maternal deaths.
This figure was arrived at after interviewing family members of the deceased. It was believed that the number of deaths was actually around 140 since most families continue to under-report maternal deaths.

The audit revealed that the average age of marriage for girls in Purulia was 17. None of the girls interviewed had been to school while the average number of years their husbands had spent in school was four years. While 61% of deaths occurred in a health facility, 24% died at home and another 13% died en route to a health facility. The majority of deaths occurred during labour and in the post-partum period.

InfoChange News & Features, March 2007