Five Years of NRHM-JSY and more than a decade of RCH: continuing maternal deaths in Barwani and MP
Background
Janani Suraksha Yojana (JSY) was launched under the National Rural Health Mission (NRHM) in
April 2005 as a safe motherhood intervention, with the specific objective of reducing maternal and
neo-natal mortality by relying on institutional delivery as the primary strategy for making available
medical care during pregnancy, delivery and post delivery period, and thus promoting safe
motherhood. All women are encouraged to avail institutional care during pregnancy and delivery,
and through ASHAs recruited specifically for this purpose institutional delivery is being promoted
among poor pregnant women. JSY is a 100 % centrally sponsored scheme, and it links cash
incentives to pregnant women with hospital delivery and post-delivery care. Reproductive and
Child Health (RCH-I) has been operational since 1997 as a project to provide a variety of
reproductive and child health services in rural areas to bring down maternal and infant mortality, in
order to reduce fertility rates and achieve population control. The second phase of the program
(RCH-II) also commenced in 2005. NRHM itself was launched with the promise to improve
availability and accessibility to health care services to the rural population, especially the
disadvantaged groups including women and children, by strengthening public health systems for
efficient service delivery, improving access, enabling community ownership and demand for
services, enhancing accountability and promoting decentralization.
It is against this context of programmes and interventions and associated fund flows from
the central government and several international agencies that one needs to view the status of
public health services, of maternal and child health in the country in general and specifically in the
high-focus states like MP, and the developments in Badwani that is the focus of this report.
Mass protest against maternal deaths in District Hospital, Barwani
On 28th December 2010 a rally was held in Barwani town, the headquarters of a predominantly
adivasi district in south-western MP. Nearly a thousand people gathered under the banner of
Jagrit Adivasi Dalit Sangathan (JADS), a mass organisation, to protest against extremely
negligent treatment of women in pregnancy and labour, particularly the death on 29th November
2010 of Vypari bai, an 8-months’ pregnant woman admitted in the District Hospital.
The people had come for this rally
from far-flung adivasi villages of the
district, and sought to draw attention to and
to protest against extreme callousness and
ill-treatment regularly meted out to women
in pregnancy and labour by the public
health system, particularly the District
Hospital (DH). A quick perusal of the DH
records indicated that between April-
November 2010 there had been 25 maternal
deaths, and 9 maternal deaths had been
recorded in this hospital in the month of
November 2010 alone. In addition, deaths
of 21 neonates (within 24 hours of birth) had been recorded, related to 511 deliveries conducted
in the hospital during November 2010. People complained that women with problems during
pregnancy and labour were frequently referred to Indore Medical College Hospital, located 150
kms away, despite the DH being supposed to deal with such cases.
The tragic story of Vypari bai – ‘institutional death’ instead of ‘institutional delivery’
Vypari bai, a 22 year old woman had travelled over 55 kms from her village Ban since the
morning of 27th November 2010 to reach the District Hospital, having been referred from the
PHC at Bokrata, and then from the CHC at Pati. She had been carried in a `jhuli’ (cloth sling)
over the first 10 kms from her village to Bokrata, from where the family managed to get the
Janani Express ambulance. She had experienced a convulsion that morning, and had high blood
pressure (BP) and eclampsia at the time of admission in the DH around 1.30 pm on 27th
November.
Following her examination by a gynaecologist at the time of admission in the DH on 27th
Nov., she was visited only once by another doctor during the entire day on 28th Nov. She had been
prescribed medicines after admission to control her BP, but her treatment sheets show only two
measurements of BP during the entire stay from 27th to 29th Nov. No attempt seems to have been
made to deliver the baby, by either induction or cesarean, as is the standard procedure in such
cases. An ultrasound scan on 28th November (for which the woman was taken by auto-rickshaw to
a private centre even though the hospital has this facility) showed the presence of live foetus.
Both the mother and mother-in-law of Vyparibai are trained health workers, presently
working as ASHAs in the NRHM. The mother-in-law Dunabai in desperation attempted to contact
the gynaecologist, who never turned up to see the patient in spite of repeated pleas from the
patient’s family. Moreover the doctor on duty, after checking the patient only once on 28th, was
also absent from the hospital premises. After repeated efforts to contact her, at late night at around
11 pm on 28th November, she instructed the nurse on duty that the relatives could take the patient to
Indore, but did not bother to examine the patient or modify the treatment. When the family went to
the doctor’s residence (which is within the hospital premise at a stone’s throw from the ward) on
28th night to ask her to attend to the woman as she was in great pain, the doctor refused to go,
saying she would phone the instructions to the nurse. The young woman finally breathed her last at
5 am on 29th November 2010, without medical attention despite being admitted in the District
Hospital.
Both the block CHC and Barwani DH are CEMONC (Comprehensive Emergency Obstetric
& Neonatal Care) centres, and the DH is equipped with a Blood Bank. Such centres are supposed
to provide emergency services related to pregnancy/ delivery round the clock and 365 days a year.
In any case, a hospital at the level of district hospital is supposed to provide emergency services at
all times, whether or not it is a CEMONC. Further, there is provision that in case of complications,
CEMONC centers can contract-in services of private medical practitioners. So she could have been
referred under the ‘Janani Sahayogi Yojana’ to one of the two local private hospitals. The DH has
four gynaecologists and two anaesthetists, who could have ensured Vypari bai’s delivery. However,
the case paper shows that nearly 35 hours after admission, the patient had been referred to the
medical college hospital in Indore at around 11 PM on 28th. Further, the family was asked to sign
an undertaking, stating that they were refusing to take her to Indore and they took responsibility for
the consequences. It has been repeatedly experienced that, rather than using the institutional
provisions, patients are generally referred to Indore. And are also made to sign such undertakings.
Several other cases of denial of services leading to complications and ill-treatment at all
levels of health services have been documented by JADS. Few illustrative ones are described
below.
District Hospital, Barwani – Baltabai, 20 years, Village- Ubadagad, Pati Block,
On 6th June 2010, 9-months’ pregnant Baltabai was taken to Pati CHC with labour pains, by bus at around 12
o’clock in the afternoon. There was no doctor in the CHC. When the family contacted the BMO and
requested him to see Baltabai, the BMO did not do so, but simply arranged for the Janani Express
Ambulance and referred the patient to the District Hospital. Around 3 PM Baltabai was admitted in the
female ward of the DH. Not a single doctor was present in the female ward, ostensibly because `it was
Sunday’. The nurse on duty informed the doctor who was supposed to be on duty, but was not physically
present in the hospital premises, about the serious condition of Baltabai. She was advised some blood test,
and after the blood report was available, referred by the doctor to M.Y. Hospital, Indore. During this period
the relatives were not adequately informed about the condition of the patient and need for referral. What is
more serious is that the family was not informed about intrauterine foetal death. Following the nurse’s
advice to go to the local hospital instead of Indore, the family took Baltabai to the private trust hospital in
the Barwani town, where the doctor examined Baltabai and informed them that the foetus was dead. She
recommended an emergency operation to remove the dead foetus and save the mother. The family had no
option but to go ahead with this surgery. They incurred a cost of around Rs 10,000/- and an additional Rs.
7000/- were spent on medicine. The family, dependent on daily-wages, had to borrow money from local
money lenders at very high interest rate.
On 14th June Baltabai was discharged from the trust hospital. However, her agony was not
over yet. On reaching home that evening she complained of abdominal distension and pain. On 15th
June, at 4 am she was taken to a private practitioner, where she was cathetarised, and again referred
to the DH, where she was treated till 21st June. On 21st June Baltabai was referred to M. Y. Hospital
Indore for treatment of paraplegia. What exactly happened to Baltabai from15th – 21st June is not
very clear, largely because there are no trustworthy clinical records. Why and how Baltabai
developed paraplegia was never explained to the family members and other concerned people.
Fortunately Baltabai’s condition improved in the M.Y. Hospital and she was subsequently
discharged on 1st July. The ordeal of Baltabai lasted for 24 days (6th June to 30th June), and has left
the family severely indebted.
In September 2008 a woman in labour at the District Hospital was referred by the attending
doctor to Indore as a case of obstructed labour. The family took her to the local Trust hospital,
where a caesarean operation was performed and the child delivered safely. However, due to the
delay the child developed complications and had to be admitted in the neo-natal intensive care unit
(NICU) in the DH.
CHC-Pati block – Meera, Patel phaliya , Pati
Meera had symptoms of threatened abortion since the second month of pregnancy; and was treated
at CHC, Pati. However, the doctor advised her that she should not rely on the medicines available
in the hospital, and made the family purchase injections and medicines from outside the hospital,
worth about Rs 1000-1200. Meera followed all the instructions given by the doctor, as she was told
that she would have a difficult labour. Despite this treatment Meera had intrauterine bleeding one
morning. When she called up the CHC for the Janani Express ambulance she was told that since
she was from Pati itself, she should go to the hospital by herself, and would not be provided the
ambulance. The lady walked over 5-8 km, for almost 2 hours, bleeding and in terrible pain, to reach
the CHC. At the CHC, she was informed that the baby had died in the womb. The family was
forced to purchase few special medicines from outside for the operation to remove the dead foetus.
PHC Menimata – Baniya Bai
On the night of 11th November 2008 Baniya bai went to the PHC Menimata for delivery. The
compounder and nurse asked her family for Rs 100, which the family did not give. The next
morning she was forced to leave the hospital on grounds of being anaemic. Baniya Bai, in
labour pain, managed to crawl out to the road outside the PHC, where she delivered with the help
on the local dai. She was then sent by members of JADS to CHC Silawad by the Janani
ambulance.
These are not isolated cases; there are reports of similar incidents of maternal deaths and
denial of treatment at the health centres, including the DH in Barwani.
Demanding Accountability for Negligence
We were visiting Barwani to get a firsthand
account of the situation there
concerning health services, particularly
in the District hospital. On the morning
of 28th December when we tried to meet
the CMHO and the concerned lady duty
doctor (who happens to be the CMHO’s
daughter) we were told that they were
out of town. The gynaecologist who had
admitted Vypari bai on 27th November
said she had anemia and eclampsia and
was not in a condition to be operated
upon; and that they did not have a
ventilator in the hospital. This
gynaecologist was not around the day
after admission (28th November) to monitor the progress; she is usually out of the hospital four
days of the week performing sterilization operations in family planning camps.
We observed the rally taking place outside the DH on 28th December. About 500 people
(nearly half of them women) had gathered at the entrance of the DH at around 12 noon, by which
time the OPD was almost over. The 2-3 doctors present there left when they heard the rally
approaching. The police tried to snatch away from the rallyists their microphone and the cart on
which it was placed; however the rallyists managed to convince them that they would leave very
soon. About fifteen minutes later the people moved away from the hospital premises and
continued their dharna on the road in front of the Collectorate office, well away from the DH.
Several activists and ordinary village women, including the mother-in-law of the deceased
Vyaparibai spoke of their travails at the DH. A set of 22 issues concerning the District hospital,
which were mentioned in the memorandum of demands, were read out to the assembled people.
The Civil Surgeon was asked for, but he refused to come out to receive the petition; finally the
ADM came and just gave a brief assurance that the issues would be responded to in writing in 15
days time. By around 4 PM the rally had dispersed.
Response by the administration – ‘the message is secondary, crack down on the messenger’
We met the Collector on 28th December evening after the rally and apprised him of the state of
affairs in the DH. It emerged that the process of carrying out maternal death reviews had not
been carried out in case of any of the 25 maternal deaths. During our meeting with the Collector,
the CMHO and CS came when they were summoned. According to the CMHO such maternal
deaths keep occurring, that women here were very anaemic, and it was ‘not possible to bring
them down to zero’. When pointed out that the DH was a CEMONC centre, that there were 4
serving gynaecologists and 2 anaesthetists, and it was enquired why such institutional deaths
were still taking place, there was no satisfactory response. The Collector appreciated our
bringing things to his notice, and said he would initiate
the task of Maternal Death Reviews. At the same time,
he also hinted at linkages of the mass organisation with
‘Bastar’ and ‘Andhra Pradesh’, thereby seeking to
discredit the people’s organisation as being associated
with the ‘Naxalites’, who have been outlawed by the
central government.
We are now extremely shocked and dismayed
that two days after this rally (on 30th Dec.) as per local
press reports, the police has foisted several charges on
the leaders of JADS and 200 people who participated
in the protest. They have been charged with Sec 146 of
IPC (unlawful assembly, rioting, armed with deadly weapon which when used is likely to cause
death), Sec 186 IPC (obstructing public servant in discharge of public functions), and Sec 16(3)
of MP Kolahal Rules. On 31st December one of the activists of the organisation, Bachhiya bhai,
was arrested and sent to jail on charges that were slapped on him and others in 2008, when they
had protested against the denial of services in PHC Menimata (described above).
It needs to be mentioned that the pilot phase of community-based monitoring of rural
health services in MP under NRHM had been implemented in Barwani during 2007-08. Even
prior to this the mass organisation JADS had been actively addressing the health problems in the
area in several ways. In May 2008 a three-day programme of monitoring of services at the CHC
Pati and dialogue with health officials (with the intention to improve them), was followed up
with a rally at Barwani town on the dismal state of health services in the DH. So the area has a
history of peaceful rallying for improvement of rural health services. However, there seems to
have been hardly any concerted response from the administration to address the genuine
problems faced by and raised by the people.
Is the situation restricted to Badwani?
The situation regarding maternal deaths seems to be similar in many other districts of MP. The
audit report of NRHM in MP by the CAG gives an idea of the serious situation in the state.
According to the CAG audit report for the period 2005-06 to 2008-09 incidences of maternal and
infant deaths in MP remained high. In the 12 districts surveyed for the audit there had been 1377
maternal deaths in all in the four-year period – Betul recorded 152, Bhopal 269, Indore 162,
Shahdol recorded 393, Dhar recorded 125, Ujjain 124, and so on. Shahdol district reported 55
maternal deaths in 2008-09. The audit report also points out that despite increase in number of
institutional deliveries, post-delivery mortality remained alarmingly high. The Maternal Mortality
Rate remained high at 379 per lakh live births. Interestingly, the state government has fixed a
lower target than that of the central government for reduction of MMR and IMR. While NRHM
envisages MMR of less than 100 per lakh live births and IMR of 30 per 1000 live births by 2012,
the MP government has set these at less than 220 and 60 respectively. It has said that due to
shortage of manpower it was not possible to achieve the NRHM targets! The audit also found that
Maternal Death Review Committees were to be constituted at each district, but had not been done.
A large number of neo-natal deaths also seem to be occuring: according to figures (collected by
RCH – NRHM for monitoring and evaluation) between April-November 2010, there were 154 neonatal
deaths in the entire district of Badwani, of which 133 have been recorded at the District
Hospital (3879 deliveries recorded at the DH in the same period).
Some other findings of the CAG audit indicate that even after four years of NRHM the
state government was not taking adequate measures to address the long-standing problems of
lack of basic medical facilities, lack of physical infrastructure, and of doctors and other staff.
For instance: the number of health centres fell short of the prescribed norms; several centres,
particularly sub-centres were functioning without buildings; none of the institutions had been
upgraded to Indian Public Health Standards (IPHS); of the 82 CHCs designated as first referral
units (FRUs) 80 percent were non-functional and the rest were only partially functional. The
state government itself acknowledged that the health centres are non-functional due to shortage
of man-power. 101 out of 297 PHCs in the 12 districts studied were running without doctors,
despite the provision for hiring contractual staff under NRHM. Monitoring Committees too at
state and at lower levels to review the activities under NRHM had not been formed till 2009.
One also finds that several hundreds of crores of rupees have been spent over the past few
years under RCH-JSY. Government reports show that the allocations for RCH-JSY had increased
since 2005, and expenditure too had increased from Rs 26.29 crores in 2005-06 to Rs 344.87
crores in 2008-09. By 2009-10 Rs 797.65 crores from NRHM funds had been spent on activities
to improve maternal and child health.
Issues and Concerns
We wish to draw attention to the grave situation that seems to be building up in places like
Barwani. It is now more than a decade of RCH and five years since NRHM, RCH-II, JSY etc,
were launched as flagship programmes. On one hand, the government is spending several
hundreds of crores of rupees annually, is vigorously promoting institutional deliveries as a
panacea for high maternal and infant mortality, and talks of safe and guaranteed health services;
through processes such as community monitoring it is promoting the idea of demanding
accountability from the public health machinery. On the other hand, the ground reality in places
like Barwani shows little change. And when people get organized to demand accountability
through peaceful actions, attempts are made to discredit and ‘brand’ their leaders, to intimidate
and repress them, and to shield the responsible officials who seem to be to completely indifferent
to the plight of the patients.
One finds that in spite of several interventions and expenses of crores of rupees, women
continue to die in large numbers. Majority of these deaths are avoidable and completely
unacceptable. It is precisely these preventable deaths that JSY claims to address, right from
ante-natal care (ANC) to post-delivery care of mother and new-born, by getting the pregnant
women to register soon after pregnancy and `motivating’ them to go to a hospital for delivery.
However, the ground reality indicates that the government is not improving the `health’ of the
health facilities in order that they treat satisfactorily women in labour, especially those with
complications. This is corroborated by the findings of the audit of the performance of NRHM in
MP. The experiences of ill-treatment narrated by the rural women also point to the apathy of the
doctors and the poor quality of care they receive when they come in pain and suffering.
How many more such `institutional deaths’, complications and denial of services, are to
occur before the hospital doctors become responsible and accountable; before the state health
department, the health ministry, the rogi kalyan samitis, the district health societies, the
numerous managers, planners, consultants, and international agencies look beyond their
ritualistic exercises of working on technical assistance, planning, evaluating, re-evaluating, replanning,
merely recording numbers of pregnant women registered, of institutional deliveries and
of beneficiaries etc., in the name of safe motherhood and child health, and seriously take note of
the reality of the deaths of women and infants?
Dr Abhay Shukla – National Joint Convenor, Jan Swasthya Abhiyan
Dr Indira Chakravarthi – Public Health Researcher, Delhi
Rinchin – Bhopal
8.1.2011
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