#India – One woman doctor for entire district of Mewat #Believeitornot


Aditya Dev, TNN May 16, 2013,
GURGAON: There is an acute shortage of doctors in government hospitals of Mewat. Surprisingly, the district with the worst maternal mortality rate and infant mortality rate, there is only one woman doctor available for the whole of Mewat. However, the apathy could be judged by the fact that the gynecologist has joined the health department only about 10 days ago.

The institutional delivery rate in Mewat is 42% implying only 42 out of 100 deliveries take place at hospital. A health official said these deliveries are done by staff nurses in absence of doctors. Sources said the health institutions are in a bad shape with two of the three community health centres (CHCs) at Punhana and Ferozepur Jhirka in the districts are without senior medical officers (SMOs) for a long time. In their absence, medical officers (MOs) have been made incharge of these CHCs.

Moreover, instead of two medical officers at each of 10 primary health centres (PHCs), there is only one medical officer appointed at present, said sources.

At CHC, Nuh, against the staff postings of 12 medical officers (MOs) and one SMO, there are only 3 MOs and one SMO are deputed.

The population of Mewat is 11 lakh and out of that 5.5 lakh alone lives in Nuh. In such a scenario, the medical facilities are too little to provide any kind of service to residents. A health official said the burden could be gauged that there should be one CHC over a population of 1.2 lakh. There is also a shortage of ASHAs (Accredited Social Health Activists) in the district. ASHA, a trained female community health activist from the village itself who work as an interface between the community and the public health system, plays an important role in providing key services to mother and child and spread awareness. A health official informed that out of 1,200, only 500 are available in Mewat.

This is when the criteria of appointing an ASHA was relaxed from class VIII literate to just any woman who can carry basic duties. Even after that we have not been able to fill the postings, the official added.

When contacted, BK Rajora, chief medical officer, Mewat, said, “There is a shortage of doctors, but the government gives priority to their appointment in the district. The problem is that many of them do not join here even after appointment. What can one do in such a scenario? Doctors do not want to come because of basic living facilities in Mewat.”

The government is also providing difficult area allowance to doctors posted in Mewat, Rs 25,000 per month for specialist and Rs 10,000 per month for other doctors.

Rajora added that besides one gynaecologist joining the office, four doctors have been given training in this field and providing emergency services. There are 53 MOs available out of 79. Almost 50% of positions are filled.

 

Maternal Health Activist Madhuri of JADS arrested #Vaw #Tribalrights


 

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

 

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

 

 

Madhuri of JADS has been arrested for fighting against contnuing Maternal Deaths In Barwani #Vaw #Tribalrights


 

 

English: National Rural Health Mission of India

 

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

 

 

 

 

 

National Urban Health Mission (NUHM) as a sub-mission under the National Health Mission (NHM)


PIB PRESS RELEASE

The Union Cabinet gave its approval to launch a National Urban Health Mission (NUHM) as a new sub-mission under the over-arching National Health Mission (NHM). Under the Scheme the following proposals have been approved :

1.        One Urban Primary Health Centre (U-PHC) for every fifty to sixty thousand population.

2.        One Urban Community Health Centre (U-CHC) for five to six U-PHCs in big cities.

3.        One Auxiliary Nursing Midwives (ANM) for 10,000 population.

4.        One Accredited Social Health Activist ASHA (community link worker) for 200 to 500 households.

The estimated cost of NUHM for 5 years period is Rs.22,507 crore with the Central Government share of Rs.16,955 crore. Centre-State funding pattern will be 75:25 except for North Eastern states and other special category states of Jammu and  Kashmir, Himachal Pradesh and Uttarakhand for whom the funding pattern will be 90:10.

The scheme will focus on primary health care needs of the urban poor. This Mission will be implemented in 779 cities and towns with more than 50,000 population and cover about 7.75 crore people.

The interventions under the sub-mission will result in

·         Reduction in Infant Mortality Rate (IMR)

·         Reduction in Maternal Mortality Ratio (MMR)

·          Universal access to reproductive health care

·         Convergence of all health related interventions.

The existing institutional mechanism and management systems created and functioning under NRHM will be strengthened to meet the needs of NUHM. Citywise implementation plans will be prepared based on baseline survey and felt need. Urban local bodies will be fully involved in implementation of the scheme.

NUHM aims to improve the health status of the urban population in general, particularly the poor and other disadvantaged sections by facilitating equitable access to quality health care, through a revamped primary public health care system, targeted outreach services and involvement of the community and urban local bodies.

Background

The Union Cabinet in its meeting held in April 2012 has already approved the continuation of the National Rural Health Mission (NRHM) and the other sub-mission under NHM till 31.3.2017.

 

#Fellowship- Maternal Health #India #mustshare


THE MATERNAL HEALTH YOUNG CHAMPIONS PROGRAM

 

 

 
Maternal mortality is a major threat to women’s lives in developing countries. While maternal health outcomes have improved in some countries over the past few decades, rates of maternal death remain alarmingly high. Every minute, a woman dies in pregnancy or childbirth and over 300 million women in poor countries suffer from maternal morbidity. In many very poor countries the majority of mothers do not receive even the most basic health care, and quality care during childbirth – when both the mother and child are most at risk – is often unavailable.
 
Program Overview
To reduce maternal mortality and morbidity over the long-term, emerging public health leaders need to be equipped with the skills, commitment, and vision to respond fully to multiple causes and consequences of this threat.
 
Maternal Health Young Champions are students or young graduates in public health or a related field who are committed to improving maternal mortality and morbidity through either research or innovative field work in their home country.
Maternal Health Young Champions Program, a partnership between the Institute of International Education and Harvard School of Public Health, offers a unique fellowship to 10 young people who are passionate about improving maternal health in their home country. The Young Champions who are selected will be matched with in-country mentors from selected organizations for a nine-month research or field project internship focusing on a particular area of maternal health. The fellowship includes leadership training and participation in the Global Maternal Health Conference 2013 in Arusha, Tanzania.
 
Eligibility Requirements Applications are currently being accepted from candidates from Ethiopia, India, Mexico, and Nigeria who meet the following minimum criteria:
  • Bachelor’s or equivalent degree
  • 20-35 years of age
  • Clearly articulated plans for continued technical experience, research, or study
  • Demonstrated career commitment to improvement of maternal health, especially in developing countries
  • Interest in academic research or technical service provision in the field (excluding policy advocacy)
  • Articulated work/study project goals
Please circulate this information widely within your institution or networks, particularly to candidates whom you think would be excellent applicants for this program.

For more information on the program or to apply, go to www.iie.org/mhyc or contact:

John Bodra
Program Officer India
Tel: +91-11-2651-6873                     Email: info@iieindia.org.in

APPLICATION DEADLINE-NOVEMBER 10, 2012

 

Ray of hope for tribal infants, moms


 

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

 

Saturday, Aug 4, 2012, 8:49 IST
By Dilnaz Boga | Place: Mumbai | Agency: DNA

 

Despite the slim chances, Mayur Bhagat survived.

 

In Waghwadi’s Shahapur block in Thane, two-month-old was breathless and suffering from acute nasal and chest congestion when he was rushed to Dhakne’s sub-centre. But no doctor was present there. He was treated by a doctor on a field visit.

 

Bhagat received treatment through Community Health Initiative (CHI), an initiative of Impact India Foundation (IIF). Two million tribals in Thane are reaping its benefits.

 

CHI is a part of the National Rural Health Mission and is being implemented in the Parali primary health centre of Wada block in Thane. “Since May 2012, it has been working to reduce malnutrition, infant and maternal mortality,” said IIF’s general manager (special projects) Neelam Kshirsagar. The Wada block is home to approximately 60,000 tribals

 

Read more here

 

U.S. Health Law May Curb Rising Maternal Deaths


 

By Malena Amusa

WeNews correspondent

Monday, July 30, 2012

As the U.S. maternal mortality rate continues to increase, the new health care law could offer improvements in preventative care for women. Yet, definitive answers to why more American mothers are dying remain scarce

Credit: Celine Vignal on Flickr, under Creative Commons 2.0 (CC BY-NC-SA 2.0)

(WOMENSENEWS)–The future of pregnant women in the United States will significantly change Aug. 1.

That is when the new health care law, the Affordable Care Act, will require insurance providers and Medicaid to cover clinical preventative services for women, including pre-natal care, all without charging a co-pay, co-insurance or a deductible.

Under the new guidelines, millions of women will gain access to health care services for free, including well-woman preventative care visits and screenings for gestational diabetes and sexually transmitted infections. These guidelines do not include maternity care or simply any service the doctor orders. However, starting in 2014, all maternity care will be covered by all new individual, small business and government exchange plans.

“This will provide an extraordinary opportunity to improve women’s health not only during pregnancy but before, between and beyond pregnancy, and across the life course,” said Dr. Michael C. Lu, the associate administrator of the Maternal and Child Health Bureau of the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services.

Not only will preventative care be provided next year without cost to women, under the new health care law, $125 million will go this year to the Maternal, Infant and Early Childhood Home Visiting Program to expand maternal and newborn support for mothers at home.

The changes are being introduced amid a wealth of data indicating that the number of mothers dying in America during or shortly after pregnancy is consistently growing. The rate of maternal mortality in the United States has more than doubled, rising from 6.6 deaths per 100,000 live births in 1987 to 16. 1 per 100,000 live births in 2009 – the highest among developed nations, Lu’s agency reports.

Various studies have attributed higher risk of maternal death to race, income, region, C-section rates, obesity-related problems and chronic disease. States where poverty exceeded 18 percent, the immigrant population exceeded 15 percent and the C-section rate exceeded 33 percent had 77 percent, 33 percent and 21 percent higher risks of maternal mortality, respectively, a 2007 report by Gopal K. Singh of the Health Resources and Services Administration indicated.

Women’s eNews has also reported previously that African American women’s maternal mortality rates are higher than those of other American women. African American women, regardless of levels of income and education, are three to four times more likely to die as a result of pregnancy. Yet conclusive data answering the question of why are scarce.

Government Funding

Ahead of the federal health insurance reform, several states have already been using funds provided by the federal government’s Maternal and Child Health Services Block Grant Program to improve pregnancy care.

For example, the California Maternal Quality Care Collaborative develops toolkits, protocols and recommendations for hospitals to tackle the leading causes of maternal death and morbidity, including hemorrhage (excessive bleeding) and preeclampsia (extreme high blood pressure).

At least two-thirds of California hospitals have adopted the toolkits. At the same time, the collaborative is devising a program to reduce first-birth C-sections, which range from 15 percent to 45 percent of births in California.

“The challenge is getting hospitals to adopt recommendations and change, but this is an area that we are making real progress in,” said Dr. Elliot Main, medical director of the collaborative. “It’s a shame mothers are still bleeding to death in the United States.”

In addition to the block grant, the Maternal and Child Health Bureau has developed intervention programs for low-income women at risk of having a low-birth weight baby, including the Home Visiting program and Healthy Start.

In 2009, 685 U.S. mothers – up from 548 in 2007 – died of pregnancy-related complications during or within 42 days of the end of their pregnancy, according to unpublished data provided by the Health Resources and Services Administration.

As a result, the United States is one of 23 countries – including Zimbabwe and Costa Rica – where maternal mortality rates have increased, according to a 2010 World Health Organization report “Trends in Maternal Mortality: 1990- 2008.”

Many pregnant mothers go into labor with chronic health problems, the top being diabetes, hypertension, obesity and cardiovascular disease. The federal maternal health agency reports that these contribute to poor maternal outcomes, but these studies are not conclusive and do not explain the maternal mortality difference between white, African American and Hispanic mothers.

Higher rates of health disorders are reported during pregnancy as well. In 2008, among the 27 states that collect this information, gestational diabetes and pregnancy-related hypertension were reported in 40.6 mothers per 1,000 live births and 38.7 mothers per 1,000 live births, respectively.

Clear Backsliding Trend

Final maternal mortality and morbidity data for 2010 are not yet available but the trend is clear. While developing countries are lowering their maternal mortality rates, the United States is backsliding.

The problem here does not correlate to monetary expenditure. The United States spends more on health care than any other country and more on maternal health than any other type of hospital care, according to a 2010 report by the London-based human rights group Amnesty International.

Lu, at the Maternal and Child Health Bureau, has been researching maternal distress for years.

“To improve maternal mortality in America, there are two things we must do,” he said in an e-mail interview. “First, we need to improve women’s health before they get pregnant. Second, we need to improve the quality of care that women receive during pregnancy.”

That echoes an international consensus that maternal deaths are preventable in most cases and that maternal morbidity can be foreseen and addressed long before the mother gives birth.

Improving women’s health before pregnancy involves what Lu has described as a “life course model” that begins in early life and extends to checkups for teens and access to contraceptives, all of which are covered by the health reforms about to take effect.

“Programs and policies that improve women’s health before they get pregnant, including those that address social determinants of health over the life course, as well as those that improve the quality of care women receive during pregnancy, will be critical for offsetting the risks which contribute to increased maternal deaths,” Lu said.

Malena Amusa is a freelance reporter based in St. Louis.

 

Adding It Up: Costs and Benefits of Contraceptive Services Estimates for 2012


Wekker voor anti-conceptiepil / Alarm clock fo...

Wekker voor anti-conceptiepil / Alarm clock for birth control pills (Photo credit: Nationaal Archief)

HIGHLIGHTS
June 2012

  1. In 2012, an estimated 645 million women in the developing world were using modern methods—
  2. 42 million more than in 2008. About half of this increase was due to population growth.
  3. The proportion of married women using modern contraceptives in the developing world as awhole barely changed between 2008 (56%) and 2012 (57%). Larger-than-average increases were seen in Eastern Africa and Southeast Asia, but there was no increase in Western Africa and Middle Africa.
  4. n  The number of women who have an unmet need for modern contraception in 2012 is 222 million. This number declined slightly between 2008 and 2012 in the developing world overall, but increased in some subregions, as well as in the 69 poorest countries.
  5. Contraceptive care in 2012 will cost $4.0 billion in the developing world. To fully meet the exist-ing need for modern contraceptive methods of all women in the developing world would cost$8.1 billion per year.
  6. n Current contraceptive use will prevent 218 million unintended pregnancies in developing coun-tries in 2012, and, in turn, will avert 55 million unplanned births, 138 million abortions (of which0 million are unsafe), 25 million miscarriages and 118,000 maternal deaths.
  7. n  Serving all women in developing countries who currently have an unmet need for modernmethods would prevent an additional 54 million unintended pregnancies, including 21 millionunplanned births, 26 million abortions (of which 16 million would be unsafe) and seven million miscarriages; this would also prevent 79,000 maternal deaths and 1.1 million infant deaths.
  8. n  Special attention is needed to ensure that the contraceptive needs of vulnerable groups suchas unmarried young women, poor women and rural women are met and that inequities in knowledge and access are reduced.
  9. n  Improving services for current users and adequately meeting the needs of all women whocurrently need but are not using modern contraceptives will require increased financial com-mitment from governments and other stakeholders, as well as changes to a range of laws, poli-cies, factors related to service provision and practices that significantly impede access to and use of contraceptive service.

Download full report here

Maternal Deaths Halved in 20 Years, but Faster Progress Needed


Eritrean women

Eritrean women (Photo credit: Wikipedia)

UN News
The report “Trends in maternal mortality: 1990 to 2010”, shows that from 1990 to 2010, the annual number of maternal deaths dropped from more than 543,000 to 287,000 – a decline of 47 per cent. While substantial progress has been achieved in almost all regions, many countries particularly in sub-Saharan Africa will fail to reach the Millennium Development Goal (MDG) target of reducing maternal death by 75 per cent from 1990 to 2015.

Every two minutes, a woman dies of pregnancy-related complications, the four most common causes being: severe bleeding after childbirth, infections, high blood pressure during pregnancy, and unsafe abortion. Ninety-nine per cent of maternal deaths occur in developing countries; most could have been prevented with proven interventions.

“We know exactly what to do to prevent maternal deaths: improve access to voluntary family planning, invest in health workers with midwifery skills, and ensure access to emergency obstetric care when complications arise. These interventions have proven to save lives and accelerate progress towards meeting the Millennium Development Goal 5,” said Dr. Osotimehin.

Disparity exists within and across countries and regions. One third of all maternal deaths occur in just two countries – in 2010, almost 20 per cent of deaths (56,000) were in India and 14 per cent (40,000) were in Nigeria. Of the 40 countries with the world’s highest rates of maternal death, 36 are in sub-Saharan Africa.

Similarly, Eastern Asia, which made the greatest progress in preventing maternal deaths, has a contraceptive prevalence rate of 84 per cent as opposed to only 22 per cent in sub-Saharan Africa, a region that has the highest rates of maternal death.

The Midwives Service Scheme in Nigeria


  • Seye Abimbola1*, Ugo Okoli1, Olalekan Olubajo1,Mohammed J. Abdullahi1, Muhammad A. Pate2,3

1 National Primary Health Care Development Agency, Abuja, Nigeria2Federal Ministry of Health, Abuja, Nigeria, 3 Duke Global Health Institute, Durham, North Carolina, United States of America

Citation: Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) The Midwives Service Scheme in Nigeria. PLoS Med 9(5): e1001211. doi:10.1371/journal.pmed.1001211

Published: May 1, 2012

Abbreviations: ANC, antenatal care; LGA, local government area; MMR, maternal mortality ratio; MNCH, maternal, newborn and child health; MSS, Midwives Service Scheme; NC, north central; NE, northeast; NMR, neonatal mortality ratio; NW, northwest; PHC, primary health care; SE, southeast; SS, south south; SW, southwest; WDC, Ward Development Committee

* E-mail: seyeabimbola@hotmail.com

Summary Points

  • Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth.
  • To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas.
  • The midwives are posted for 1 year to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care.
  • The outcome of the MSS 1 year on has been an uneven improvement in maternal, newborn, and child health indices in the six geopolitical zones of Nigeria.
  • Major challenges include retention, availability and training of midwives, and varying levels of commitment from state and local governments across the country, and despite the availability of skilled birth attendants at MSS facilities, women still deliver at home in some parts of the country.

Introduction

Nigeria, with more than 140 million people, including 31 million women of childbearing age and 28 million children under the age of five, is by far the most populous African country. However, the maternal mortality ratio (MMR) in Nigeria is 545/100,000 live births, as only one in three births in Nigeria is attended by skilled personnel, less than 20% of children are fully immunised at age one, and 36% of pregnant women do not receive antenatal care (ANC) [1]. Thus, strengthening these services is an urgent imperative.

Midwives Service Scheme: The Rationale

The slow rate of progress in Nigeria makes the Millennium Development Goals (MDGs) targets unachievable using current strategies alone [2]. Health indices in Nigeria vary widely across geopolitical zones (See Box 1) and socioeconomic groups [3]. The northeast (NE) zone has the highest MMR: 1,549/100,000 live births compared to 165/100,000 live births in the southwest (SW). There are also urban and rural variations with MMR of 351/100,000 live births in urban areas compared to 828/100,000 in rural areas. The under-5 mortality rate of 171/1,000 live births also varies between the lowest (219/1,000 live births) and highest (87/1,000 live births) wealth quintiles. This pattern is replicated in other indices of childhood mortality. Maternal, neonatal, and child mortality rates in Nigeria are highest in the NE and northwest (NW) zones and lowest in the southeast (SE) and SW [1]. However, although the rates are lower in the SE and SW, indices in these regions still fall short of global development targets.

Box 1. The Political Organisation of Nigeria

Nigeria is divided into 36 states and one Federal Capital Territory (FCT), which are further sub-divided into 774 local government areas (LGAs). There are six geopolitical zones in Nigeria: north central (six states and the FCT), northeast (six states), northwest (seven states), southeast (five states), south south (six states), and southwest (six states).

These variations in health indices are influenced by the presence of tertiary hospitals, social amenities, and a population that can afford to pay for health services that in turn attract highly skilled health workers [4]. Therefore, in much of rural Nigeria, beyond issues of access, there are inadequate human resources for providing 24-hour health services in primary health care (PHC) facilities [5]. Nigeria faces a crisis in human resources for health (HRH) in the form of health worker shortages, requiring an immediate and significant increase in the number of health workers [6], or in the meantime a strategic redistribution of health workers to grossly underserved rural areas (See Box 2).

Box 2. The Political Economy of Health Care in Nigeria

Health services in Nigeria mirror political organisation. The federal government is responsible for tertiary care, state governments for secondary care, and the local governments (LGs) run primary care. Health financing is tied to the flow of funds from the federation account, which are shared between levels of government according to an allocation formula that keeps about half of funds at the federal level, the 36 states share a quarter, and the other quarter is distributed to the LGs. These resources are not sectorally earmarked and the states and LGs are not constitutionally required to provide budget and expenditure reports to the federal government. This results in poor coordination and integration between levels of care, giving rise to a weak and disorganised health system with widely varying patterns of outcomes. The MSS is an unprecedented emergency stop gap collaborative effort among the three tiers of government to improve maternal and child health indices in rural Nigeria.

Efforts to better reach underserved communities have been on task shifting to community health workers (CHWs) [7]. While task shifting has offered a cost-effective expansion of the overall HRH pool, skilled attendance at birth is essential to reducing the burden of maternal mortality [8]. The shortage of skilled birth attendants in rural Nigeria impacts negatively on utilisation of services by women in these areas [5]. Launched in December 2009 , the Midwives Service Scheme (MSS) was set up to address the HRH needs in rural primary care, based on the evidence that when the number of midwives increases, utilisation of services increases, women’s satisfaction with care improves, and maternal and newborn mortality decrease [8],[9]. To do this, three categories of midwives were recruited as part of the MSS: the newly graduated, the unemployed, and the retired. They are posted for 1 year (renewable subject to satisfactory performance) to selected PHCs in rural communities.

Midwives Service Scheme: The Structure

The facilities selected for the MSS were linked in an effective two-way referral system through a cluster model in which four PHC facilities with the capacity to provide basic essential obstetric care were clustered around a general hospital with the capacity to provide comprehensive emergency obstetric care. There were 815 participating health facilities: 652 PHC facilities and 163 general hospitals. Each PHC facility has four midwives to ensure 24-hour provision of skilled birth attendance at all times, as well as other maternal and child health services.

MSS Geographical Distribution

The number of facilities in each of the six geopolitical zones was selected on the basis of maternal mortality burden. Nigeria was divided into three zones (Figure 1) according to MMR: very high MMR (NE and NW), high MMR (north central [NC] and south south [SS]), and moderate MMR (SE and SW). NE and NW have six clusters per state, SS and NC have four clusters per state, and SW and SE have three clusters per state. The project currently serves an estimated aggregate of 15 million people in Nigeria.

thumbnailFigure 1. The states of Nigeria and their MMR categories.

Red (northeast and northwest), very high MMR; yellow (north central and south south), high MMR; green (southeast and southwest), moderately high MMR.

doi:10.1371/journal.pmed.1001211.g001

Selection of MSS Facilities

Participating PHC facilities and general hospitals were selected based on rigorous criteria. Selected PHC facilities are in hard-to-reach areas or among underserved populations with a population of 10,000 to 30,000 people. The PHC facilities have potable water supply and offer 24-hour basic health services with minimum equipment including blood pressure apparatus, weighing scale, and basic laboratory diagnostic facilities for malaria and anaemia. Selected general hospitals provide basic services including ANC, child delivery, postnatal care, and family planning; comprehensive emergency obstetrics care and prevention of mother-to-child transmission of HIV (PMTCT) services; administration of antibiotics and intravenous fluids; and treatment of pre-eclampsia. The general hospitals have at least 12 maternity bed spaces, a functioning operating room, blood bank, and stand-by alternative power supply.

Midwives Service Scheme: The Process

Recruitment

The midwives under the scheme are selected with adherence to the International Confederation of Midwives (ICM) global standards for midwifery education [10]. The minimum entry level of students for midwifery education is completion of secondary education, and the minimum duration of A-Level-entry midwifery education is 3 years and 18 months for post-nursing midwifery education. The maximum age limit for recruitment is 60 years. Following an initial nationwide recruitment exercise, 2,488 (instead of the expected 2,608) successful midwives were deployed to 652 designated PHCs in the 36 states and Federal Capital Territory (FCT) on the scheme—45% of them are unemployed midwives recruited to the scheme, 44% are basic midwives during their mandatory pre-registration community service year, and 11% of them are retired midwives.

Continuing Medical Education (CME)

To enhance the quality of their services, midwives are trained quarterly in life saving skills (LSS) and integrated management of childhood illness (IMCI). The competency-based training sessions are conducted at schools of midwifery in each state. The trainings run for 6 consecutive days and the class size varies from 24 to 32 people. The training programme involves interactive theoretical and illustrative lectures with skills demonstration and practical sessions. There are initial practical sessions on dummies, then on consenting patients in the wards towards the end of the course. Participants partake in a course review and tests to assess the effectiveness of the training.

There are no defined entry criteria for the CME, as recruitment into MSS is an ongoing process to cope with the challenge of attrition. Thus, all recruited midwives are eligible for participation in both training programmes.

Political, Financial, and Community Commitment

Given the high level of fragmentation in the governance of the Nigerian health system (see Box 2), a crucial initiative of the MSS programme was for state and local governments to sign a memorandum of understanding with the federal government agency responsible for PHC in Nigeria, the National Primary Health Care Development Agency (NPHCDA), which is also the implementing agency for MSS. The state governments are expected to match with N20,000, the N30,000 monthly remuneration paid to the midwives by the federal government through NPHCDA.

In addition to the monthly stipend, the federal government provided basic health insurance coverage for all the midwives, provided midwifery kits for each of the participating PHC facilities and each midwife, and supplied a personal health record booklet, basic maternal and child health equipment, drugs, registers, and monitoring tools. The federal government funds the CME and provides technical support to the states and local government areas (LGAs) on the implementation, supervision, monitoring, and evaluation of MSS.

The state governments support the use of general hospitals as referral facilities for the MSS by upgrading the hospitals to provide comprehensive emergency obstetric and newborn care, including basic equipment and supplies such as drugs and other consumables, ambulance services, steady electricity and potable water supply, stationery, and security for health workers and equipment. The state governments also monitor and supervise the programme within their jurisdiction and coordinate the provision by LGAs of free decent accommodation in the host communities and at least N10,000 supplementary allowances for the midwives.

For each PHC facility, a ward development committee (WDC) made up of influential people in the community is established to enhance community participation and ownership and to promote demand for services. The WDCs meet monthly to discuss health and other developmental issues in the community under the supportive supervision of the LGAs. During the monthly WDC meetings, the midwives address any concerns of the community and brief the community on their work within the month, including their challenges. The WDCs in turn provide support to the midwives by ensuring their security and accommodation. While they do not routinely provide direct financial support for women seeking care, the WDCs support the transportation of pregnant women and neonates in cases of emergency. In addition to their clinical duties, the midwives serve as change agents in the target communities by working with WDCs to mobilise the people for health action and promoting women and child health care and home visits. Training for these roles is part of the basic midwifery training, and the midwives are involved in the creation of the WDCs.

Midwives Service Scheme: The Outcome

Monitoring and Evaluation Platform

MSS implementation was preceded by establishing key baseline maternal, newborn, and child health (MNCH) indicators to define goals and provide a clear framework for future evaluation. There was a nationwide survey conducted at all the facilities (primary and secondary) and communities where the intervention was located. Table 1 shows the seven core indicators of progress in the MSS, nationwide data from the Nigeria Demographic and Health Survey (NDHS) 2008, baseline data from the MSS primary care facilities, and the gains that the scheme hopes to achieve by 2015. Even though facility-based data are expected to reflect better indices, the baseline survey shows that MSS target areas are worse off compared to the national average (data from Nigerian Demographic and Health Survey 2008) even though the national data is population based.

thumbnailTable 1. MSS core indicators and projected outcome, with data comparing 2008 NDHS with MSS facility baseline data.

doi:10.1371/journal.pmed.1001211.t001

Impact of the MSS

Figures 25 show MNCH indicators for the six zones comparing data from mid to the end of 2009 and mid to the end of 2010. The gains of MSS have not been even across geopolitical zones, although it shows an overall improvement in the MNCH indices.

thumbnailFigure 2. MSS facility-based maternal mortality ratios comparing July–December 2009 with July–December 2010.

NE, northeast; NW, northwest; NC, north central; SS, south south; SE, southeast; SW, southwest; MSS, Midwives Service Scheme.

doi:10.1371/journal.pmed.1001211.g002

thumbnailFigure 3. MSS facility-based neonatal mortality ratio comparing July–December 2009 with July–December 2010.

NE, northeast; NW, northwest; NC, north central; SS, south south; SE, southeast; SW, southwest; MSS, Midwives Service Scheme.

doi:10.1371/journal.pmed.1001211.g003

thumbnailFigure 4. MSS facility-based maternal health indicators comparing July–December 2009 with July–December 2010.

ANC, antenatal care; TT, tetanus toxoid; FP, family planning.

doi:10.1371/journal.pmed.1001211.g004

thumbnailFigure 5. MSS facility-based maternal health indicators percentage increase from July–December 2009 to July–December 2010.

ANC, antenatal care; TT, tetanus toxoid; FP, family planning.

doi:10.1371/journal.pmed.1001211.g005

The facility-based MMR in the same period in 2010 was 572 compared to 789 per 100,000 live births for the same period in 2009. However, facilities in the NE and SE did not show a decrease in MMR when compared to 2009. The facility-based neonatal mortality ratio (NMR) in the same period in 2010 was 9.3 per 1,000 compared to 10.97 per 1,000 live births for the same period in 2009. Facilities in the NE, NW, and SW did not show a decrease in NMR when compared to 2009. The maternal health indicators show a general overall improvement over baseline: family planning visits, pregnant women with new ANC visits and those with at least four ANC visits, facility-based deliveries, and the number of women receiving two or more doses of tetanus vaccine.

The lack of improvement in MMR and/or NMR in specific zones may be due to an increase in the proportion of high risk deliveries in the MSS PHC facilities. As shown in Figure 4, the majority of the women who attend facilities ANC still deliver at home. The additional deliveries in MSS facilities are likely to be among women with high risk pregnancy who present too late for life saving interventions in pregnancy or the neonatal period. We hope that the continued presence of skilled birth attendants in the communities will ensure positive behaviour change, especially in seeking early and routine interventions from the PHC facilities.

These data provide useful information on the progress of MSS 1 year from establishment. There have been overall improvements in the provision of MNCH services in rural areas that usually lack skilled birth attendants such as midwives. The data also provide a powerful tool for advocacy to support the scheme particularly in the NE zone where the gains have been limited.

Midwives Service Scheme: The Challenges Top

  • The project is currently funded from the debt relief granted to the Nigerian government by the Paris Club. The greatest threat to MSS is the uncertainty about continued funding beyond the 3-yearcommitment from the grant. However, the National Health Bill passed in 2011 promises to further provide secure funds for the administration of PHC in Nigeria [11]. The state governments are encouraged to be fully involved in MSS programmes, as the plan is for them to gradually take over the scheme in their respective states.
  • Implementation of the memorandum of understanding signed with state and local governments is a persisting problem. This mainly involves provision of accommodation for the MSS midwives and irregular or delayed salary payment by state and local governments. Regular monitoring of the PHC facilities and midwives by field agents from the NPHCDA serves to coerce the state and local governments into fulfilling their roles.
  • Availability of qualified midwives poses a challenge to the success of the scheme particularly in the areas of most need: the NE and NW. Ongoing recruitment and deployment of midwives to these areas are strategies employed to overcome this problem.
  • Retention of midwives in the scheme is one of the major challenges. Most of the newly graduated midwives (44% of MSS midwives) are young, single, or newly married; a particularly mobile cohort who tend to return to their home zones (usually southern zones) after the completion of their 1-year mandatory pre-registration participation in the MSS. However, another set of newly graduated midwives replace the ones who leave at the end of the 1-year mandatory pre-registration programme.
  • Inadequate social amenities, language barriers between the midwives and the local community, and working in hard-to-reach rural areas are some of the factors responsible for attrition. Strategies and incentives used to overcome this include attractive pay package and provision of ambulances, accommodations, and health insurance coverage for the midwives. Some hard-to-reach areas in the northern zones (NC, NE, and NW) were further provided with an additional 1,000 CHWs. Two CHWs were deployed to each facility and they provide support and complement the work of the midwives. They are also encouraged to spend time within the community to identify women and children who need care and refer appropriately. There is a long-term plan to identify and train locals to become midwives who will then work within their own communities. There are also ongoing discussions around providing supervised home delivery as part of the MSS in order to better reach women, especially in northern Nigeria, who present for ANC, but choose to deliver at home for sociocultural reasons.
  • Current training of the midwives focuses mainly on LSS and IMCI. However, there is a need to also train them on other various critical aspects of health care such as PMTCT, family planning, and information and communications technology (ICT) skills. There is also a need for capacity building of the PHC team beyond just midwives.

Conclusion

The MSS strategy of the Nigerian government recognises that strategically redistributing and improving the skill set of existing cadres of health workers is achievable on a large scale. The initiative potentially serves as a model for other developing countries within and outside sub-Saharan Africa who may need to redistribute their health workforce to reduce the inequities that exist among geographical zones and between urban and rural areas.

Author Contributions

Wrote the first draft of the manuscript: SA UO. Contributed to the writing of the manuscript: SA UO OO MJA MAP. ICMJE criteria for authorship read and met: SA UO OO MJA MAP. Agree with manuscript results and conclusions: SA UO OO MJA MAP.

References Top

  1. National Population Commission (NPC) (2009) ICF Macro. Nigeria demographic and health survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro.
  2. Overseas Development Institute (2010) Millennium Development Goals (MDG) report card: measuring progress across countries. Available: http://www.odi.org.uk/resources/download/5027.pdf. Accessed 22 March 2012.
  3. Harrison KA (1997) Maternal mortality in Nigeria: the real issues. Afr J Reprod Health 1(1): 7–13.FIND THIS ARTICLE ONLINE
  4. WHO (2006) Working together for health: the World Health Report 2006. Available:http://www.who.int/whr/2006/whr06_en.pdf. Accessed 22 March 2012.
  5. Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, et al. (2006) Going to scale with professional skilled care. Lancet 368(9544): 1377–1386. FIND THIS ARTICLE ONLINE
  6. WHO/UNAIDS/PEPFAR (2008) Task shifting: global recommendations and guidelines. Geneva: WHO. Available: http://www.who.int/healthsystems/task_shifting/en/index.html. Accessed 22 March 2012.
  7. Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, et al. (2007) Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med 357(24): 2510–2514. FIND THIS ARTICLE ONLINE
  8. Campbell OM, Graham WJ (2006) Strategies for reducing maternal mortality: getting on with what works. Lancet 368(9543): 1284–1299. FIND THIS ARTICLE ONLINE
  9. Betran AP, Wojdyla D, Posner SF, Gulmezoglu AM (2005) National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity. BMC Public Health 5: 131. FIND THIS ARTICLE ONLINE
  10. International Confederation of Midwives (ICM) (2010) Global standards for midwifery education. Available: http://www.unfpa.org/sowmy/resources/docs/standards/en/R427_ICM_2011_Global_Standards_for_Midwifery_Education_2010_ENG.pdf. Accessed 22 March 2012.
  11. Federal Government of Nigeria (2011) National health bill 2011. Available:http://www.herfon.org/docs/Harmonised-NATIONAL-HEALTH-BILL-2011%20doc.pdf. Accessed 22 March 2012.

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