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Community Health Cell
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Community Health Learning Programme
January to February 2010
REPORT
Deepa Sai
intern, Community Health Cell
0
ACKNOWLEDGEMENT
Firstly, I would like to thank Community Health Cell for providing me with a platform to
complete my internship and conduct my research in the public health sector.
I owe the successful completion of this project to my internship guides Dr.Rakhal and Mr.
Ameer Khan for lending their support and guidance whenever I needed it.
I would like to thank my respondents Dr. Satya, Dr. Sukanya, Dr. Subha, Dr.Rajasekar and
Mrs.Renuka for giving me the technical exposure and resources required to complete my
research.
I express my gratitude to the members and health activists of Rural Women’s Social Education
Centre (RUWSEC) and Tribal health Initiative (THI) for giving me an orientation about their
projects and providing me with an opportunity to participate in discussions and learn about the
public health sector in Tamil Nadu. I would also like to thank them for giving me a memorable
time during our interaction.
1
CHAPTER I
INTRODUCTION
Safe motherhood and institutional deliveries have been talked about as an integral part of public
health in Tamil Nadu. I wanted to gain an insight in the area of public health especially in the
field of institutional deliveries in Tamil Nadu. The basis for which have been explained to be the
following:
Previously I have had one of my internships with an organization named Mobility India in
Bangalore city, Karnataka. Its services are targeted towards people with disabilities especially
the projects are focused on the people residing in the slums of Bangalore. The director of the
organization told me that majority of the people who are disabled are from the slums. The
creamy layer of the population gets access to all the services, not affordable by the others. That
is why the organization goes to slums & seek them, providing services instead of them seeking
for help. So I spent a lot of time in the households of those slums interviewing the mothers who
had children with disabilities. My findings at the end of the internship were as follows: There
was usually one community doctor and the women don't go for check-ups .They get 50 rupees
per day to feed the whole family. Poverty dominated most of the households there. At least
twice they attempt suicide while pregnant. Many mothers weren’t empowered enough to take
decisions regarding children and to go out to seek treatment. Also some mothers who had
children with disabilities had delivered at home with out any skilled assistance.
I went for a visit to a non governmental organization (NGO) named Tribal Health Initiative at
Sittilingi, near Dharmapuri, Tamil Nadu. The tribal inhabitants of the village that is women as
old as 17 and 19 are trained by the NGO members and the tribal hospital senior staff, for
managing deliveries, complications and assisting in surgeries. The hospital was very friendly
and the infra structure was built resembling the houses of the tribal inhabitants of the village.
The hospital is given a very homely atmosphere with many traditional equipments. I was also
allowed to witness a delivery. It was a very life altering experience for me also. The hospital
was well equipped; the staffs were efficient and friendly. Some beneficiaries mentioned that it
was not only safe to deliver a baby there but also it would be a very enriching and satisfying
experience.
I also attended a community focused group meeting at an NGO RUWSEC. What is safe
motherhood all about and the necessities required for a safe motherhood were being discussed. If
safe motherhood can be achieved at homes also. And the quality of public health institutions and
their services were evaluated.
2
CHAPTER II
REVIEW OF LITERATURE AND RESPONDENTS
Gupta, Hemangini (2008, May 17), ‘The Return Of The Midwife’, Tehelka Magazine,
Volume 5, Issue 19.
This article cites some incidents where there were inappropriate birthing practices in hospitals. A
mother had an instance where tablets were shoved in, Pitocin used to accelerate labor, water bag
ruptured, epidural injected, nurses held her legs and screamed at her, and finally she was given a
cut and fundal pressure exerted.
The article also talks about a term called “birth rape’ involving Inserting objects into a woman’s
vagina without her consent and being rude and abusive to women in labor violating women s
and children’s rights as quoted by a health activist.
Some hospitals use caesarean sections, to speed up the birth process since a normal labor takes
up to 12 hours.
A mother quotes that for most mothers caesareans had been induced, had their membranes
ruptured, undergone cervical stripping, a routine episiotomy and a regional anesthesia thrown in,
all under the guise of a ‘normal delivery’.
A midwife mentions that mothers do not have their voices to complain against the system since
doctors are paternalistic.
The mothers in these articles after having traumatic experiences in hospitals about the birthing
process have opted for home birthing centers. And also describe the process as a very satisfying
one.
A neo-natalogist quotes that traditional midwives can handle deliveries but are not equipped for
complications. For those times they can be equipped for referring on time and working with
obstetricians.
http://www.tehelka.com/story_main39.asp?filename=crl70508the_retum.asp
Dr. Sudhakaram V, (2009, March 9), ‘Institutional Deliveries in India - A Socio Economic and
Cultural View’, Women’s health articles. Retrieved from www.articlebase.com*
The article quotes that social and cultural aspects on institutional deliveries is important as India
has the largest no. of births in the world (27 million) and with high maternal mortality of 300500 per one lakh births. It describes the various causal factors for low utilization of delivery
services being distance from health services, costs that includes user fees, the cost of transport,
quality of care, drugs availability and supplies, attitudes of the health personnel, multiple
demands on women’s time, women’s lack of autonomy in decision making.
Poverty plays a major role and India has a lot of BPL families and is related to other causes like
literacy, availability of health services. Norms and traditional beliefs about child birth coupled
with misconceptions fears of medical institutions, have led to low utilization maternal health
services. Shame in the first birth and newly pregnant girls are expected to exhibit modest
behavior by remaining calm in their vital condition and not talk at all about the presnancy, the
social pressure may create a major barrier to seeking antenatal care or deliverins in hospital
Overcoming some old norms and beliefs and knowing herself about the physiolosy of pregnancy
is important. Woman's education is a major factor affecting utilization of maternal health
services in both north and south India as quoted by an earlier research. Transport availability
availability of care givers, distance from health care facility, the cost including the user fees the
quality of health care in India with shortage in human resource in health sector and the attitude
3
of health personnel towards the patient and their higher absenteeism to the duties questioning the
improvement of utilization of maternity health services are important causes too.
The inability of women to make decisions in relation to choice of medical care severely affects
their choice of delivery care. A conflict between biomedical and traditionally perceived causes
of health conditions also limits women's access to deliver}' care. Scheduled caste and scheduled
tribes mothers living in urban areas are more utilizing the maternal health sendees.
Demographic factors like increase in the Maternal age has a strong positive effect in utilizing
deliver}' services. Increase in the birth order has a negative in the maternal service utilization
Also Unmarried pregnant girls are less likely to utilize the maternity health services.
http://www.articlesbase.com/womens-health-articles/institutional-deliveries-in-india-a-socioeconomic-and-cultural-view-808672.html
Mint (2008, May 6), ‘India’s health system neglects midwives’, article .Retrieved from
Oneworld.net*
The article quotes incident of a traditional birth attendant (TBA) along with 100 midwives from
11 states and their civil society organizations were in the capital to make a representation to the
government for having a more defined and concrete role in public health programmes,
specifically the National Rural Health Mission (NRHM) to re-examine their de- legitimization
and to bring them back into the mainstream public health domain. After having been part of the
public health system for generations, these TBA-dais find themselves on the periphery,
marginalized and ignored as castaways.
The director for Health and Social Justice quotes that points out that for the last three decades,
dais have been put through training modules, funded by governments and international agencies,
and now suddenly they have been declared redundant. However, there is a Dai association in
Gujarat running successfully.
More than 60% deliveries in rural India continue to be at home since a dai recounts that the
mothers are ill treated at the maternal health services and not many PHCs function. The article
claims that since dais represent marginalized sections of society and are illiterate, their
candidature is weak. The dais argument is that if they cannot be recruited as ASHAs, they
should still be retained in the system so that they can help the women who may otherwise be
denied safe delivery and post-partum care.
http://us.oneworld.net/article/india ’s-health-system-neglects-midwives
Menon, Meena (2008, July 6), ‘Delivery on roadside, peon gives injections’ (Electronic
version), The Hindu. Retrieved from www.thehindu.com*
This article quotes about an adivasi dominated area near Mumbai, India where women are
delivered of babies on the road, peons give injections in the primary health centre and the doctor
collects donations in a neat little metal box kept on his consulting table. Later a public hearing
was conducted as part of community monitoring to register complaints.
The article quotes an incident where a mother was refused at various hospitals and her family
members were victims of corruption.
Also it is quoted that adivasis were treated badly at PHCs where often women in the family had
to clean up after a delivery and dispose of the placenta and the umbilical cord as the PHCs do
not have disposal facilities.
The article quotes that in one PHC, peon Pandu gave injections to people and charged them Rs.
20 under doctors’ instructions. Also a doctor was charged against forcing people to drop money
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in a donation box. Also there are institutional gaps were there is juts one contractual staff
receiving pay every four months catering to a crowd of 1,000 people a month, out-patients
Department remains closed for 10 or even 15 days at a time, no sanitation, misuse of funds, and
forcing people to buy medical equipments.
http://www.thehindu.com/2008/07/06/stories/2008070659721000.htm
Meiselas, Susan (2009, October 7), ‘India: Too Many Women Dying in Childbirth’, Human rights
Watch. Retrieved from www.hrw.org.
The article quotes about high number of maternal deaths despite various government programs
.The article also quotes a report called "No Tally of the Anguish: Accountability in Maternal
Health Care in India" documenting gaps in health care provisions and steps to address them in
Uttar Pradesh. The report cites numerous examples of cases in which breakdowns in the system
ended tragically.
Quoted by a health activist, accountability of maternal deaths is very less and no actions taken
will be successful unless accountability is high.
The human rights watch research has showed a lot system gaps despite the NHRM launch that is
very low quality maternal death audits and also the absence of accessible grievance and redress
mechanisms, including emergency response systems. The research also pointed out lack of
facilities, corruptions among the staff and untrained staff in PHCs
The article claims that this happens because many women are unaware of their health rights. The
complaints of these women and the ASHAs are not being addressed.
http://www.hrw.org/en/news/2009/10/07/india-too-many-women-dying-childbirth
Meiselas, Susan (2009, November 4), ‘India: Reveal Truth about Childbirth Deaths’,
Human rights Watch. Retrieved from www.hrw.org.
The article cites that India is unable to meet international commitments to improve obstetric care
because of various health system gaps. Human Rights Watch research shows that women with
pregnancy complications are able to get appropriate care during childbirth despite government
programs guaranteeing free service to rural women. AS quoted by a health activist, women are
dying preventable deaths whose causes have not been pinned down.
The article quotes the gaps in the Government lacking appropriate monitoring logistics and
services for maternal and infant death audits and also maternal morbidity in the immediate post
partum period.
The health information system has some of these dates but is the data collection consistent and
effectively used for maternal health programs is a doubt. Cases have been documented in which
women died after childbirth even though they gave birth in health facilities. In these same
districts, government health records showed "zero" deaths.
The Indian Government treats huge amount of institutional deliveries as progress but failed to
measure the quality of these health services to as to say that safe motherhood can't be directly
attributed to institutional deliveries. Poorly equipped health facilities coupled with poor referral
systems are serious barriers to timely care for pregnant women. Cases of pregnant women
seeking emergency obstetric care being sent from one clinic to another desperately seekino care
has been cited.
As quoted by a health activist, unless there is certification for health staff and proper monitorino
of public and private health facilities , safe motherhood can not be guaranteed.
http://www.hrw.Org/en/news/2009/l 1/04/india-reveal-truth-about-childbirth-deaths”
5
‘Rural TN rises against corruption’ (2008, December 9), article show, the Tinies of India.
Retrieved from www.timesofindia.indiatimes.com
The article cited talks about a laborer at Coimbatore who was forced give bribe the
administrative officer to process her petition regarding Dr.Muthulakshmi Maternity assistance
scheme but she reported the issue to the anti corruption office to get her issue resolved. A village
administrative officer was caught for receiving a bribe of Rs 6,000 for issuing a birth certificate.
http://timesofindia.indiatimes.com/articleshow/msid-381 0595,prtpage-1 .cms
Rajalakshmi,T.K.,(2009,November?),‘Maternal Trajedies’,Frontline,Volume 26, Issue 23 *
The article cites that there area high number of maternal deaths happening in the country and the
policies should consider welfare of women and children regardless of caste or income. A report
titled “No Tally of the Anguish” focused on Uttar Pradesh, published by Human Rights Watch.
has been quoted. A study by WHO says that, India alone contributes to a little under a fourth of
the world's maternal mortality, with 450 maternal deaths for every 100,000 births.
The report by Human Rights Watch basically criticizes the Government, in maintaining the
maternal death records. Poor maternal health care continues to be pervasive among the poorer
sections, in particular the marginalized Dalit communities, the MMR in Uttar Pradesh is three
times higher than that of Tamil Nadu. There is a lack in facilities for basic and also emergency
obstetric care, there is very less care for the immediate post-natal period of 48 hours of delivery.
Even after institutional deliveries, there is no follow-up effort to record whether the mother
survived the post-natal period without injuries, disabilities or infections. The women who use
the government health facilities do not complain against health providers for fear of reprisals
from doctors and health workers. The report also criticizes the Janani suraksha yojana schemes
not being open to pregnant girls under 19 and women who already have two children. There is
no information about the type of care that women get. Uttar Pradesh, the report says, has the
worst civil registration systems in the country. The report quotes the direct causes of maternal
deaths being hemorrhage, sepsis and unsafe abortions and indirect causes being tuberculosis.
viral hepatitis, anemia and malaria. The report claims that setting a statistical target to reduce
maternal deaths is meaningless without proper health systems and nutrition.
http://www.hinduonnet.com/fline/fl2623/stories/20091120262309600.htm
Respondents
I met Dr. Satya who is a pediatrician at Chengalpet Government hospital. I met the deputy
director of health services of Kanchipuram district, Dr. Rajasekhar. I also met the Maternal and
child health officer of the same district, Mrs. Renuka. I also had some views from Mr.Ameer
Khan, a health activist of the NGO Community Health Cell. I interviewed Dr. Subha, a health
activist heading a federation called Rural Women’s Social Education Centre (RUWSEC). She
had wanted to define safe motherhood (technical, social) and bring about indicators of safe
motherhood. So she had some focus group meetings with health workers and beneficiaries of
nearby villages who are a part of RUWSEC. And I had the opportunity to participate in the
meetings for exposure and interaction.
6
CHAPTER HI
ANALYSIS AND INTERPRETATION
Maternal Mortality Rate (MMR)
Dr. Subha mentioned that at first infant mortality was a huge issue till a document named
‘Where is the M in MCH ?’ (Rosenfield, A.; Maine, D.), was published in 1985. The article
questioned as to why so little importance was given to the mother in maternal and child health
(MCH) programs. After that, maternal mortality became an urgent issue to be attended world
wide. Many schemes were adopted by the government of India too. Under Janani Suraksha
yojana (JSY) scheme, comprehensive emergency services were formed and deliveries were
pushed to PHCs. The supply of these services was lesser than the demand. There was a slow
raise in institutional deliveries from 25% to 80% from 1970s onwards. But the scheme was a
failure due to fewer supplies. But in Tamil Nadu, the scenario was different where supplies were
higher than the demand so it was an immediate success right from the 1980s.
Traditional Birth Attendants (TBAs)
Dr. Subha mentioned that first home deliveries were present in the villages. They were
conducted by traditional birth attendants (TBA). The Indian government to stop maternal
mortality started various interventions .One of them was to train midwives in villages who
conducted home deliveries. The project was abandoned entirely deeming the training as a
failure. The training module for the dais where not evaluated. There were no steps taken by the
government to check the flaws in the training. Instead, the dais were blamed for their lack of
knowledge for the failure of the training.
Mrs. Renuka mentioned that midwives no longer conduct or assist in deliveries. They have all
been debased and stripped off their jobs. But a few are now retained in the Public health
centers(PHCs) as sanitary workers .They are allowed to do only menial jobs and earn around
Rs.500 per month. They are not recognized by the government as authorized experts for
conducting the deliveries.
Government’s Attitude toward Home Births
Home births are considered as something very unhygienic and barbarous by government staff
and public health officials alike .According to them, safe motherhood can happen only at PHCs
with technical provisions and schemes. People at homes do not know how to handle deliveries.
There is no electricity, no space to have equipments and equipments can't be brought to homes.
Especially in the poor people’s houses, mothers lie on the floor for delivery. And some mothers
work till the day before the delivery. In case of an emergency or a sudden labor, brineine these
mothers to the PHC will be difficult, as it’s difficult to locate them in interior villages.
But the scenario would be different if the mother arrives at the PHC a day before the delivery
and stays there for three days. While she is there she can be properly monitored. Complications
can be easily referred to specialized hospitals. Audits and accountability of emergencies and
deaths can be recorded as the centers are located at accessible areas for the health staff All these
services cannot be done on a door to door basis by sending the nurses and the public health staff
to interior villages to households who have pregnant women.
Dr. Rajasekar complains that mothers in the villages give sugar water to babies and the babies
die. Dr. Satya points out that some traditional birth attendants (TBAs) cause infant deaths They
give oil bath for the babies and blow into their mouths and noses to remove dirt .The babies die
of infections and pneumonia.
7
For safe motherhood, the women need to take care of birth spacing, nutrition, ante- natal check
ups and also need to have iron / folic acid abundantly. She says the mothers ought to be
counseled by social workers about negligence at home, breastfeeding, cleanliness, medication
awareness, consanguineous marriage and nutrition .The mothers are illiterate and ignorant about
such things. They do not go to higher specialists when their babies are referred, in case of
complications. They think it's a very big complication and worried about expenditure .Instead
they rely on faith based treatments.
Government’s Programs to address MMR
One of the reasons the NRHM scheme was presented in India was to reduce MMR.
Dr.Rajasekar explained about the public health infrastructure before and after the introduction of
National rural health mission (NRHM).
Upgraded 30 bedded PHC (deliveries happens all the time; x rays, operation Theatre available)
J
Block PHC (operation Theatre; 2 staff nurses available all the time)
t
PHC - caters to 30. 000 population (ANMs do a few deliveries)
Village Health Sub Centers (VHSCs)
5 or 6 available (all ANMs do delivery)
He says, there was an acute lack of quality and equipments did not function much at VHSC s so
deliveries happened at block level PHCs only. Accessing public health was a major issue for
mothers till 2005 .With the introduction of NRHM - 12 services were brought .They were: all
PHCs working around the clock , establishment of basic emergency obstetric services . RTI and
STI clinics . mobile medical units , indigenous ISM medicines, hiring of specialists , using good
amount of funds for caesarean operations and family planning services, patient welfare societies.
village health and sanitation committees, scan centers and audits , ‘108' ambulance services.
He said that he has done many innovations in health services while being posted at Vellore and
kanchipuram as a deputy director for public health. The government has evaluated those and
instructed PHCs of other districts to follow the same .It has regularly sent a team of directors
from other districts to observe these innovations to incorporate the same in other districts.
The early neonatal mortality rate is high (Safer Pregnancy in Tamil Nadu: From Vision to
Reality; WHO Monograph) .A sensitive issue in a developing country. Dr.Rajasekar mentioned
that a project is being executed to approach the causes. The reasons have been located to be
pneumonia, diarrhea, congenital problems, and asphyxia.
Government policies to reduce MMR
Dr.Rajasekar explained about the Kalaigner’s Insurance scheme benefitting families whose
annual income is less than Rs.72, 000 per year. It is not a scheme exclusively made to reduce
MMR but nonetheless it's a health scheme. People who are members of various welfare boards
can avail that scheme. There are 22 welfare boards E.g.: welfare boards of construction workers.
8
Also smart cards are given to these people that can be used by private and government hospitals.
Through this scheme families can avail around 52 types of treatment.
The Janani Suraksha Yojana (JSY) scheme was brought for BPL families to reduce MMR all
over India .It provides mothers with Rs. 1400 for their nutrition, antenatal care, perinatal and post
partum care .An improvisation of it is the Muthulakshmi Reddy Scheme (MRS) in Tamilnadu
which provides Rs.6000 instead.
Some flaws of the JSY scheme was pointed out by health activists, beneficiaries and government
officials alike. The scheme is not for mothers who
1, are below 19 years of age
2
have more than two children
3
live at husband’s house during pregnancy.
Some flaws mentioned about MRS are as follows:
Dr. Subha points out that the scheme has been manipulated by various governments that held
office through various time periods. Since then the amount has been raised from Rs. 450 to
Rs.6000 consecutively, to target mothers for getting more votes and sustaining the parties.
Also she says the amount is of no actual benefit as the families use it for getting ambulances and
other bribes.
A health activist Mr.Ameer pointed out that the mothers don’t receive the money in installments
before delivery but receive the money only after it once they register with the government. So no
money is received for nutritional purposes during antenatal period, which defies the entire
purpose of the scheme. He also pointed out that the nutrition scheme can be integrated with
middy meals scheme (MMS) in villages by providing meals to mothers everyday instead of
giving them the amount, but the government is reluctant to adopt such an idea.
Dr. Rajasekar agreed that the amount is not used for nutrition but for other multi purposes.
According to papers for MRS Rs. 1000 has to be distributed to mothers starting from the 7th
month, but that is practically impossible due to accountability issues. So mothers get the amount
at one installment after registration. He says the scheme is beneficial for other aspects because
getting a lump some amount of Rs. 6000 by BPL people by government is amazing. People also
get Rs. 500 from JSY scheme though they have home deliveries. He said that the idea of
integrating the nutrition scheme along with MMS, was articulated and government dismissed it.
He said that government has administrative and financial issues, so its not allowing funds
properly for nutrition pilot projects but compensates for that gap by providing MRS.
Mrs. Renuka said that the people who are not in the BPL category also gain money and plan for
it .They don’t use it for nutrition purposes. The money also goes to some deserving hands, which
are totally downtrodden and do not even earn an annual income of Rs.6000 per month. The
schemes are eye wash but can not be terminated totally. It can destroy livelihoods if done .She
says that integrating nutrition for mothers along with midday meals scheme will consume a lot
of time, energy and money, something that government can’t afford. The quantity can be
reached but the quality cant be assured .For the food and screening for a month the 7th , 8th and
9th month mothers have to come. For a day around 80 to 120 mothers turn up. To organize food
for them is a tough job for PHC staff. Sometimes mothers, who still are due during9th month
turn up and some mothers who are in the 6lh month also turn up. It’s not feasible to provide them
food everyday .If government can consider this and allot a separate department to executive this
project, the goal can be achieved.
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Maternal Morbidity is still an issue:
Dr.Subha says that, though Tamil Nadu government has successfully reduced maternal mortality
rates (MMR), the question of maternal morbidity has not been addressed anywhere, be it short
term or long term.
For this. Dr. Rajasekar's take is that, for maternal morbidity issues there is screening during 7lh,
8,h 9lh month for mother s to anticipate complications and treat them. E.g.: heart diseases, hyper
tension, eclampsia, gestational diabetes, infant morbidity and anemia.
But Dr. Subha complains about maternal and infant morbidity after delivery. Mainly mothers
after discharge are not followed up. E.g.: Anemia. She says she hasn’t seen public health
institutions keeping track on post partum complications, statistics and also the quality of care
received for it.
Some of the health workers quoted some incidences about system gaps especially in auditing
deaths or morbidity. Maternal or infant morbidity during delivery or within the post partum
period has to go through government auditing. The families have to be taken by the health
workers to the collector to report. In this procedure, the government hospital staff is negligent
and provides less quality services once cases are referred to them .The government staff don't
know how to tackle complications. They disrespect health workers in the villages, saying they
don't have enough knowledge. The get evasive and blame the health workers if there is health
system failure, to save themselves from higher authorities.
The cultural, gender and social discrimination in giving services
Abortion, contraception pills or family planning concepts have all become cultural and religious
issues. Dr. Subha has reported that the mothers face discrimination and have issues regarding
privacy and abortion procedures. The abortion procedures are very tedious and harmful. Women
contraceptives are not available widely in the market and if available are inaccessible by the
general population due to unreasonable costs. Married mothers do not have a problem as
government wants to promote family planning. But unmarried mothers are treated the worst, by
government health staff. The government sees premarital sex and motherhood as a blasphemy.
She has also reported that government is selective about the messages it spreads. Women
controlled options are not considered especially in the cases of safe abortions. They only talk
about condoms (male controlled) but not women controlled techniques to prevent pregnancy. No
emergency contraceptive pills are available. And for family planning, the painful manual
procedures are to be experienced by the mothers. She also prompted that there can be issues of
social discrimination when it to comes to accessibility to services that are not being discussed
anywhere. E.g. People affected with HIV, SCs, and STs. Though for family planning SCs and
STs have cash incentives .For safe motherhood in general if are there any options, is still a
question.
When enquired about the gender bias to Dr. Rajasekar, he mentions that the public health
administration is trying to popularize male sterilization and nose scalpel vasectomy, a china
procedure. The program is currently on and government is funding for it. The staff is trying to
negotiate with government to increase Oral Contraceptive Pills (OCP). Dr. Rajasekar also
countered that in Vellore 70% of PHC users are people belonging to schedule and most
10
backward (Vannier) caste .So there isn’t any special allotment for SC and STs and its equal
treatment for all people.
CHAPTER V
Reality gaps in theory and practice
Hygiene Issues:
Dr. Satya said the most listed complaints which were that the patients and the caretakers slept on
the floor due to insufficient beds. There is also no hygiene as there is one sanitary worker for an
entire building.
According to some of the beneficiaries and health workers from villages, the toilet facilities are
unsupportive as reported by beneficiaries and health activists. Some NGOs provide toilet
facilities with fees .The health facilities are late or unsafe sometimes, are not proportionate for
the number of patients. There are less quality of deliveries and vaccines.
Inadequate Staff in government Hospitals:
According to Dr. Satya, the ideal staff ratio in a government hospital ought to be
1 severe complication baby = 1 nurse
8 babies needing medication = 1 nurse
40 babies = 6/7 pediatricians
One social worker.
But in reality she points out that there is just one sanitary worker for the entire building
consisting of different departments. One pediatrician is catering to fifty babies and totally 3
nurses .There is no social worker. Staffs are really less in secondary and tertiary hospitals. No
amount of petitions and complaints has brought out radical actions on the behalf of the
government.
To tackle the problem currently, the government official says that the work load is shifted to
PHCs that at tertiary level the doctors can just take care of complications. And government is
giving certificates for diabetology and anesthesia by training MBBS holders in PHCs. He says
government is benevolent enough to have done that much.
But Dr. Satya contradicts the above claim reasoning that government is building new
government hospitals all over the state and spends money for them. Since government does not
get profit from old government hospitals, it has abandoned them totally.
Government Officials’ negligence:
Mrs. Renuka complains that sometimes when referrals are given from the PHC, the staff of
government hospitals doesn’t receive that immediately .And she recently gave complaints to the
joint directors of government hospitals to fix that up.
Dr. Rajasekar claimed that there are only a few government directors who work sincerely
Coordinating with other directors is tough for him. as there are only a few motivated directors
.Also there is always a clash between one director or another of different districts. He feels a
strain from his higher officials too. He says government sometimes is benevolent, but otherwise
it discards many ideas that are suggested due to monetary inadequacy, system gaps and staff
deprivation.
Immunization services have been moved to PHCs
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A health worker complained that for polio vaccines the VHNs are supposed come to village
households for health advocacy, antenatal checkups and polio vaccination .But now even the
immunization has been moved to PHCs. She said that the mothers find it real hard to travel to
PHCs for just an injection.
Dr. Rajasekar quoted an incident that had triggered the government to move the services to
PHCs .Two years back in Thiruvallur district of Tamil Nadu there had been four infant deaths.
Some VHNs went to village and gave immunizations for normal babies without testing them for
other issues like pneumonia or chest congestions which had caused the deaths. So, immunization
was moved to PHC where Medical officer (MO) checks for all that before administering
vaccines.
People had protested a lot but their voices were unheard. Since the government can not take
further blames. At PHCs, MOs screen, test and then administer the vaccines .Through NRHM;
they sometimes send mobile medical units (MMU), for inspections only if an MO is present.
Inefficiency of ANMs
I accompanied Mrs. Renuka for an inspection at two upgraded block PHCs. One in Parandhur
and the other one at Thuruppukuzhi of Kanchipuram districts. These were previously block
PHCs which had been upgraded as 30 bedded ones. They were conducting a food mela at
Parandhur, for all the pregnant women, giving them nutritious lunch and screening them for
complications. A pilot project innovation executed by Dr. Rajasekar in all the PHCs of
Kanchipuram district.
There were labor rooms in two upgraded 30 bedded PHCs. Mothers in all different stages of
labor were put in the same room. The women who had been aborted where also put in the same
room. And also the delivery room is not actually a separate room. It’s a small seclusion in the
same room as the labor ward. There was another delivery cabin adjacent to the current one.
which was not in use, which was badly kept. It is not put to use unless the staff had two
simultaneous deliveries. The staffs were not in their uniforms at that time and were warned by
Mrs. Renuka about it.
Dr. Rajasekar had an enquiry with an ANM in Vallam PHC, kanchipuram district during his
interview with me. The ANM had read the partograph of two labor cases the earlier day. Both
cases were in the stage of complication since 6 to 8 hours had passed and the labors had not
progressed. Despite knowing that the mothers ought to be transferred to the government hospital
as emergency, she had retained both cases at the PHC for 11 hours. She had failed to act even
after reading the partograph and so was sacked by the deputy director.
Mrs. Renuka says that unlike in private hospitals where there will be many to assist, the ANMs
have to work on deliveries single handedly by leading and taking responsibility. The ANMs
need to know the signs whenever a case gets complicated and should do referrals on time
without delay. They also need to screen the mothers earlier during 711', 8lh and 9,h month. They
should anticipate appropriately if a case should be normal or caesarean.
She complained that some ANMs are new and practically inefficient to handle deliveries on their
own. They coming from private institutions may be good in theory, but practically they are not
well informed. The current situation in PHCs is that ANMs are ill equipped to handle deliveries
so these ANMs are given training before being posted at various PHCs. The only eligibility is a
certificate authorizing them as government health workers. They are over burdened with
responsibilities and are paid Rs. 7500 per month.
Follow ups are not done
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There are also issues about follow ups done by the public health institutions. Usually the mother
stays in these institutions for three days after which she is discharged and she has to come for
regular follow ups. But some beneficiaries complained that doctors are not present for antenatal
check ups or consultancies. Mondays and Wednesdays are reserved for consultations in the out
patient departments. But the doctors never carry out consultations on Wednesdays. Even for
emergencies at 11:00 am, the clinics are closed. Bed patients are alone given consultations
Mothers in the out patient departments (OPD), for follow ups don't get consultations. The
pregnant mothers in OPDs are forced to buy beds in the PHCs.
Bribe, Violation of Patients’ rights and schemes like BCP
Some health workers complained that there are monetary issues for medicines especially before
and after delivery .The mothers are forced to buy stuff like covers, soaps, blades. Depending on
the money given, the staff takes care of patients. Government hospital doctors take bribe during
private practice at clinics, especially when mothers go for antenatal check ups. There is also an
increase in the bribe rates by government hospitals.
Dr. Satya also said that earlier people paid Rs. 1000 to Rs. 1500 for a baby for ambulance and
other services but now they get it free of cost according to government rules. But the
ambulances are also ill equipped. She says that one of the reasons for infant mortality is that
ambulances are available but there are no equipments in the ambulance for emergency. For e.g.:
Oxygen tubes are not there. By the time baby arrives to the hospital it dies. The health workers
say that Emergency transport, on papers is supposed to be free but people are charged for it.
The most prominent complaints from beneficiaries and village level health workers were that
there is a lot of physical abuse and coercion at PHIs. There is no space for complaints. People’s
basic dignity and rights are being hampered for mothers and also for VHNs alike. Many VHNs
feel the pressure from higher authorities. The mothers don’t have the rights to even choose their
hospitals.
Dr. Subha said that, once her federation RUWSEC organized an awareness talk on the birth
companionship programme (BCP). There was a huge response from the beneficiaries and they
were outraged that nobody from the government had taken initiative to disseminate such an
important scheme to them, since previously they all had faced a lot of abuse in government
hospitals when regarding caretaking. And a copy of the government order (GO) was then given
to all the women. But a lot of them were still denied access to the mothers at government
hospitals, the GOs were rejected.
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CHAPTER V
CONCLUSION
Possible ways forward
About safe motherhood, there were focused group discussions with beneficiaries, health activists
and health service providers of some districts around Chennai, organized by the NGO
RUWSEC.
They brought out a lot gaps that are present in the current public health institutions in Tamil
Nadu. And they have raised a lot of demands, to see some changes in the functioning of the
system.
According to them:
Abuse of women has to be ceased. Public health systems have to be provided with clean toilets.
Bribe and corruption has to be abolished. All services ought to be free, as they are stated on
paper. Unsafe abortion has to be checked.
Basic medical provisions ought to be given. For examples: generator, transport, ambulance,
blood banks, disposable needles, (delivery) pregnancy table, incubator, operation theatre.
They want qualified, professional medical officers that are practised professionals who can be
accessible at any time. For example : Nurses , dais , gynecologists , surgeons , child specialists ,
pediatricians , consultants / counselors (pre /post delivery ) . Follow up should be there after
deliveries for the post partum period.
Family support I social support systems need to be good. The family should be sensitized about
providing good nutrition and assisting the staff in medical procedures and birthing process and
to give appropriate psychological support. And a caretaker has to be allowed to be along with
the mother during the birthing process.
The mothers should have the right to choose hospital/ doctors I clinics. One such instance was
quoted by health activist Dr. Subha about an incident while having a meeting on safe
motherhood with some beneficiaries in a village. The women claimed that even the technical
aspects of medical policies are to be discussed with beneficiaries. And that safe motherhood is
possible at homes, and even some complications can be treated.
E.g.: A beneficiary stated home deliveries can happen at home. And that syringes can be stored
in nearby shops which can control hemorrhage etc. close to homes rather than PHCs so that
women can attend to complications at home instead of travelling to PHCs which are very' far.
And midwives can be trained in the administration of injections and better use of equipments
and medication. And safe motherhood can be practiced at homes.
They say safe motherhood can happen anywhere be it public health institutions or home. But in
reality, they have to opt for institutions since the equipments can’t be had at homes. But they
definitely wanted their right to choose whichever hospital they wanted to give birth. Safe
motherhood happening at home is an ideal condition for them now, which can be slowly put into
practicality later.
The above gives some insight and is representative of evaluation of the quality of services
received by the people from Tamil Nadu’s public health institutions (PHI). It also gives us a
picture of how far is safe motherhood being practiced in PHIs in TamilNadu. And also gives a
scope to envisage if birthing processes can be brought to homes, by adding a few
complementary services to make them effective instead of institutionalizing them.
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