Saturday, November 10, 2007

Let men do their bit

The Pioneer, Sunday November 11, 2007

Shailaja Chandra

For 30 years, vasectomy has been a political taboo, and the entire burden of family planning has been on women. But modern vasectomy techniques are a success in the West. India needs to try them

According to the projection of the Registrar General of India, India's most populous State, Uttar Pradesh, will account for 22 per cent of India's population by 2026. Half of India's demographic growth will occur in Uttar Pradesh and Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan - certainly a huge jump. Fertility rates here are destined to take decades to reach replacement levels. In contrast, the south (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) is forecast to jointly account for only 13 per cent of the population increase during the same period, having already achieved the target fertility rate of 2.1 optimally projected for 2010 for the country.

Currently, 42 per cent of India's population produces three or more children. Of 188 million couples requiring contraceptive coverage, only 53 per cent are using contraceptives. The percentage of women having more than three children is 57 per cent in Uttar Pradesh, 54 per cent in Bihar and 49 per cent in Madhya Pradesh. Almost half the girls there are under 18 at marriage and soon become mothers.

With half the population in the reproductive group using no contraceptives, there is urgent need to push up the age of marriage, delay the birth of the first child and widen the scope for spacing and limiting families. Vasectomy is a feasible way of enlarging services for a simple, safe and effective terminal method.

Unfortunately, any large-scale efforts to limit population are attacked by critics as an invasion of "human rights". Added to this, given the cultural ethos of the northern States, such goals are dumped as "unacceptable" and "impossible" and invariably shunned by many politicians who thrive on the continued ignorance of populations.

The Millennium Development Goals do not envision family planning strategies as the direct route to improving maternal and child health. This acts as a deterrent to do-gooder international or national organisations from getting involved overtly.

Concentration on maternal and child health services has unwittingly excluded men. Counselling on vasectomy is just not their business. In India, men have ceased to be the direct object of the family planning programme ever since eight million male sterilisations were conducted -- six times more than in a normal year -- coercively and haphazardly during the draconian Emergency.

Even now horror stories of three decades gone by give shudders to politicians, especially in the Hindi belt. With no other terminal option available, millions of women have perforce to undergo tubal ligations having already borne the brunt of unwanted pregnancies and repeated childbirths, not to speak of often dangerous induced abortions.

Against this background, the recent resurrection of the vasectomy programme comes as a welcome surprise. Madhya Pradesh has doubled vasectomies in the span of just one year from 7,000 operations in 2003-04 to over 15,000 the year after. An orthodox State like Haryana has steadily shown higher and higher performance each passing year. Its neighbour Punjab has quadrupled the number of vasectomies in a matter of one year. Likewise conservative Rajasthan has upped the vasectomy performance from just 1,700 during 2003-04 by almost five-times.

During a recent visit to Gujarat, I noted how vasectomy operations had increased six-fold in one year with 6,200 operations conducted in just two months inviting the headline, "Vasectomy with a Vengeance", from a national newspaper. On October 6, in a single district, Vadodara, nearly 900 vasectomies were performed and hundreds of men had clearly come willingly for this outpatient procedure.

At every health facility, ANMs in white saris and smart name tags, anganwadi workers and village women togged up in their best attire escorted the "acceptors" for vasectomy. Even the drivers and sweepers had jumped on the vasectomy bandwagon and motivated between five and 15 young men each. Surgeries progressed speedily and while the patients lounged on beds, waiting their turn, paranthas, enthusiastic counselling and a bag full of condoms were kept in readiness to complete the day's work.

Whether the carrot was the Rs 200 motivation money or the Rs 1,000 compensation for acceptors, an enormous response was clearly evident. But despite occasional peaks, India's annual vasectomy total remains less than a 10th of the pre-Emergency levels, despite hundreds of surgeons having acquired the Chinese non-scalpel skill taught largely by a veteran, Dr RM Kaza of Delhi's Maulana Azad Medical College.

In the United States, United Kingdom, Canada and New Zealand vasectomies are expensive and it is the more educated people who opt for the procedure, gently encouraged to do so by sophisticated advertisements. In India, as in Bangladesh, Sri Lanka, and Thailand, vasectomies are treated as the poor man's option. In some Latin American countries like Brazil, Colombia and Mexico, vasectomy has been presented as an alternative to female sterilisation, and by involving wives in decision-making the outturns improved.

What is needed is for decision-makers outside the health sector to stop worrying about resurrecting the ghost of 1975 and understand that our population growth is having a direct and detrimental effect on maternal and infant mortality, the birth of underweight children and their future growth and survival. In all fairness to women, it is time to revitalise vasectomy.

Thursday, November 08, 2007

Mothers and children in MP: Survival questioned

Sachin K Jain
Source -

In MP, of the 1000 children born, 70 perish before their first birthday and as many as 8.56 lakh childbirths in 2006-07 occurred at homes. The negligence of the government and society is the biggest reason for the deaths of mothers and children.

SANGRAM SINGH of Khatia-Narangi village in Baiga-tribal dominated Mandla district of Madhya Pradesh is not able to open his eyes despite many efforts. His eyelids collapse instantly and his eyes close. His skin is getting contracted. There are several questions about the chances of his survival. The weight of this 50-day child is just 2.2 kg. If such young children are capable of thinking, then Sangram Singh must be surely thinking about the unjust character of the society. He is still in critical situation and Government of Madhya Pradesh has ordered an enquiry in the Shivkali’s, his mother, death case. The term of reference of this enquiry does not contain any point to investigate the violation of child rights. They will only do a formality of investigation of death, not the violation of rights.

Sangram Singh is not just any child but a character of the story that is common for the 7700 children who are born every year in Madhya Pradesh. These are those children who do not have the good luck of receiving mother’s milk and the warmth and sensitivity of her lap. The tragic aspect is that the negligence of government and society becomes the biggest reason for the maternal deaths during childbirth.

If a woman dies within 42 days of childbirth, then the death is considered as maternal mortality. Shivkali died within 11 days of childbirth, yet the state government did not consider it as maternal mortality. As per the Health Department Mandla district did not record a single maternal death during April 2007, which means that along with life of Shivkali, the government is also denying her death. After the death of his mother, the life of Sangram is also in dire straits. At birth, his weight was 2.4 kg, which means that his development has been stunted. In such circumstances, the local health workers have refused to treat the child. Finally with the help of local social workers, Sangram was taken to a doctor Mukesh Rutela in Nainpur on May 22. Here it was diagnosed that Sangram was already entered in grade IV malnutrition category and is also suffering from various infections. At the time of birth he was not severely malnourished and if his treatment is not carried out very intensively, the chances of his survival are poor. The family is full of anger and sadness, but they are now not ready to go to government hospital.

Baiga tribal woman Shivkali had given birth to Sangram Singh on April 4 in her hutment. Local traditional midwife Jethibai assisted the childbirth. There is a primary health centre in this village. Interestingly, the village is not away from the mainstream of system. It is located just by the main gate of Kanha National Park. Ironically the objective of the Primary Health Centre located at the Khatiya village has been to take care of the national and international level tourists rather than the villagers. The PHC has now got a beautiful building, but only three to four villagers reach the PHC every day. When we reached the centre, out of the 15 member staff including four nurses, doctor, ANM and sanitary workers, only one nurse was present. Son Sai of Khatia village says that whenever one approached the centre, the message is that majority of staff have gone to block or district headquarters for some meeting. In such circumstances people are forced to go to Bicchia or Mandla. It is incomprehensible as to why the government is denying that the Baiga tribal (whom former Prime Minister Indira Gandhi had described as national people) live in a traditional setting. Because forest rights were taken away from them, they have also lost access to traditional medicines owing to which women and children are dying, but the modern medicine system is far out of their reach. If the future of the children is to be safeguarded then the government should have brought the Baigas close to modern treatment facilities in a sincere and sensitive manner.

The maternal and child mortality cannot be contained only by writing slogans on the walls or presenting unbelievable statistics. Isn’t it a serious fact that around 10 million children die every year before celebrating first birthday in Madhya Pradesh?

The effort for protection of life is also the responsibility of anganbadis, but it could only be called unfortunate that the name of Shivkali was not registered in the list of pregnant women in the local anganbadi. Naturally this pregnant woman from a poor family could not get enough nutrition to sustain herself and her foetus. However, after her death, the local anganbadi worker Shashikanta Thakur took possession of her mother-child card and filled up all details regarding completion of immunization doses. Similarly the district hospital took possession of all medical documents related to Shivkali and Sangram Singh. The amount of efforts taken to destroy evidence if taken previously could have saved lives of Shivkali and Sangram. Shashikanta waves off her responsibility saying that the tribal people do not want to get immunized or treated. “Khushiyal Singh (Shivkali’s husband) should have been more responsible. We cannot go home to home checking upon people,’’ she says. Thus the victim has been made the accused by the system. It is very unfortunate that the woman who could not even express her health problems or pains has been made responsible for her own death.

Ten per cent of the populace in MP is that of tribal communities including three primitive tribal – Baiga, Bharia and Saharia. But the state government does not have any work plan to change the innate behavioural patterns or gaining confidence of these communities. Not only this, but the 51000 odd traditional midwives (dais) who could have brought these people closer to modern medicine system have been banned from offering their services. On one hand the government is not able to provide proper health services and on the other hand it is scrapping the traditional and alternative systems.

The situation in Khatia is very unusual. Shivkali never received even a single health check up during her pregnancy period and did not get a single immunization dose. During last two years, the state government started as many as seven schemes to prevent maternal and child morbidity and mortality, of which the Vijayaraje Janani Bima Kalyan Yojana was closed down on May 11, 2007. The logic given was that the women were getting enough benefits under other schemes and thus this was not necessary. The truth is that during last year, 56 women and 807 kids perished in Mandla. Government touts that institutional childbirth is the best way to safe motherhood and that the responsibility to encourage community for this falls on health administration.

The sub-health centers and the primary health centers have to ensure that every pregnant woman should be registered within 12 weeks of pregnancy so that the regular health check up, immunization, nutritional needs and emergency treatment facilities could be ensured for her. The basic thing is that government will have to take care that health services and health workers should reach the needy people like Shivkali and Sangram. It should not be expected that women and children bearing pain and burdened by exploitation would reach the health centers and demand services.

As per the guidelines of the Government of India, all the primary health centers should have refrigerator and deep freezer to store the medicines, but at the Khatia PHC, the medicines and equipments were lying openly at temperature of 43 degrees. There are no standard arrangements of storing medicines in the 7300 sub-health centers in MP, owing to which the treatment of patients becomes risky in itself.

The issue of health demands sensitive behaviour and attitude, which means that it should be ensured that the people suffering from pains could be provided humane touch. It is a well-proven fact that total cure of any pain is not possible only through medicines. For Shivkali and Sangram, this belief could not prove to be positive.
In MP, of the 1000 children born, 70 perish before their first birthday and as many as 8.56 lakh childbirths in 2006-07 occurred at homes. The negligence of the government and society is the biggest reason for the deaths of mothers and children.

Sangram was born into tattered unclean rags at home, but after this the health of Shivkali started deteriorating. Then Shivkali’s father Mangal Singh started looking for the ANM and the health worker. As it was evening time, Jagat Singh Pande and Subhadra Pande did not pay attention to the issue and asked that Shivkali be taken to Mandla, which is 65 kms from Khatia. Under one scheme of the government, financial assistance is provided to pregnant women facing problems for reaching the health services, but Shivkali did not receive any such assistance. Mangal Singh rented a private vehicle for Rs 1200 and took her to district hospital, Mandla. They had the Deendayal Antyodaya Treatment Card, but the doctors did not pay attention to it. The lady doctor in the hospital asked for Rs 3000 from Mangal Singh for the treatment. Since it was matter of life and death for his daughter and grandson, Mangal Singh requested the doctor to start the treatment, although he had only Rs 30 left with him after paying the rent of the vehicle. Even this Rs 30 was taken away by the doctor. Mangal is also the chief of the Baiga Adiwasi Sangathan of Mandla and thus he lodged a complaint with the District Collector regarding this exploitation. Inquiry was conducted and pressure was created on the hospital administration.

But the inhumane face of the doctors came to the fore. As soon as the district administration official left the hospital, the hospital authorities refused to treat Shivkali and referred her to Jabalpur. Doctor said to Mangal Singh that, “you are a leader and only your leadership can save your daughter.” Thus Shivkali had to pay for her poverty as well as for demanding her rights, although indirectly. Left with no option, Mangal Singh decided to take Shivkali back to village, but she succumbed even before reaching the village.

Now Mangal Singh is facing a debt of Rs 5500, which he would have to repay at the interest rate of 10 per cent per month. Leave aside treatment and medicine; the family did not even receive any consolation. It is natural that no sacrifice is expected from the health workers, but could not they be expected to at least fulfill the responsibilities allotted to them.

Health worker Jagat Singh says that it is compulsory to attend meetings every month. Since targets are fixed, thus information has to be provided regularly, even if it means that there is no time left for fulfilling the targets. The health workers also have their limits; Jagat Singh says adding that what would have happened if Shivkali had died while the nurse was trying to treat her. If there are no doctors available permanently, how women like Shivkali could be saved.

Every year about 17 lakh childbirths are carried out in the State and of them 53 per cent are in BPL, tribal and dalit families. In such situation, 99 out of 137 posts of obstetricians and gynecologists are vacant. About 648 out of 4607 posts of doctors are vacant and of the rest 3133 medical officers are posted in urban and semi-urban areas. Shivkali needed blood, but although getting blood is easy for people of higher economic classes, she could not get blood. There was hospital, medicine, anganbadi as well as motorable road, yet Shivkali had to die and little Sangram is struggling for survival.

In Madhya Pradesh out of the 1000 children born, 70 perish before their first birthday. According to this rate, in year 2006-07 as many as 1.19 lakh infants could not be saved. This proved that still at the societal, political and governmental level, the right to honorable life right is a much neglected issue.

Despite efforts by the government, as many as 8.56 lakh childbirths in MP in 2006-07 occurred at homes. There are certainly efforts to rid the society of evil of maternal death through institutional childbirth. But the situation of the health centers and the inhumane behaviour meted out there is still a big challenge. In Indore, a nurse physically assaulted a pregnant woman while in Mandsaur a woman had to undergo childbirth on the road as she could not pay bribe to health workers. In Ashok Nagar, Nevabai became a victim to negligence of doctors and when the community demanded inquiry of the incident, the health administration boycotted Nevabai’s village Nidanpur. Due to this boycott, Phoolkunwar died on the road. Seems to me that the bigger reasons for maternal and infant deaths are selfishness and ego of the expert medical practitioners.