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By Rashme Sehgal Forty thousand women die every year of childbirth and related complications in Uttar Pradesh, which has the highest maternal mortality rate in the world. Now, a tussle over where to buy dai kits has stalled their distribution to village midwives, putting more lives at risk
Uttar Pradesh’s family welfare programme is being funded by both USAID and the World Bank.While the former is supporting the State Innovations in Family Planning Services Project Agency (SIFPSA), the World Bank is backing the Uttar Pradesh Health Systems Development Project. Both projects are aimed at improving healthcare delivery services in the state, especially to women. Despite this financial support, Uttar Pradesh’s maternal mortality figures are the highest in the world according to statistics collated by the National Family Health Survey of 1998-99. One woman dies every 15 minutes because of lack of proper medical attention. According to experts, maternal death is defined as “The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from a cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” In Uttar Pradesh, 40,000 women die of childbirth and related complications every year. These figures have been corroborated by the Department of Health and Family Welfare of Uttar Pradesh.. The risks are much higher for poor rural women. Visits to Kanpur, Hardoi, Sitapur, Manikpur and Mirzapur confirm the lack of healthcare facilities at primary healthcare centres. Thirty-five-year-old Ramadevi was pregnant with her seventh child at Mohalla Kheda Bibi Jai in Hardoi district. She went into labour on June 5, 2003. Her family sent for Sitawati, the village dai (midwife). According to Sitawati, Ramadevi’s baby was in the wrong position. She explained that she was unable to help Ramadevi for two reasons. Firstly, the department of family welfare (DFW) had failed to provide her with a dai kit and so she had no equipment to help in the delivery. Secondly, she suspected it would be a difficult case and suggested it was better for Ramadevi to hire the services of a private doctor. And so Ramadevi’s family took her to Asma Khatun, a local quack. Khatun and her assistant ended up hacking off a part of the baby’s body. At one point in the horrific operation Khatun told Ramadevi’s father-in-law Raman Singh that she would write out a referral slip for Ramadevi to be taken to another private doctor. By this time Ramadevi had bled to death according to Raman Singh. Although the police initially refused to file a case against Khatun, public pressure finally forced them to arrest both the quack and her assistant. This tragedy is important for two reasons. It is the department of health and family welfare’s job to monitor and ensure that quacks are forced to close shop. Its other key role is to make sure that Uttar Pradesh’s 23,000 ANMs (auxiliary nurse midwives) receive dai kits well in time to be able to distribute them to the over 100,000 trained dais who function in the state’s 94,000 villages. A dai kit costs just Rs 4 and consists of a sterilised blade, suture, a needle and other equipment that helps in a delivery. The reason why Sitawati had not received a dai kit was a tussle between Rajendra Bhonwal, secretary of the DHFW and family welfare minister Phagu Chauhan. Bhonwal wanted to buy the kits from the Uttar Pradesh Drug and Pharmaceuticals Ltd (UPDPL) company, which is reportedly selling each kit for as much as Rs 12. Bhonwal is also ex-officio chairman of the UPDPL and he disagreed with Chauhan about buying the kits from the Employees State Insurance (also a government set-up), which is reported to be selling drugs and kits at cheaper rates. The result of the tussle? The DHFW has been forced to forego the Rs 6.80 crore it received from the Pradhan Mantri Gramodaya Yojana in 2002-03. The money had been specially allocated for the purchase of dai kits and the supply of key medicines and equipment to district-level primary health centres. Bhonwal is unwilling to take any questions on the dai kit controversy. “Speak to the mantriji (minister) on this subject,” is his refrain. Meanwhile, the mantriji is busy with the elections and has not attended office for the past eight weeks. USAID, however, has a different view. Senior Delhi-based USAID officials maintain that absence of proper obstetric care is what causes so many maternal deaths in UP. “Women die due to complications such as sepsis and haemorrhaging. Such cases cannot be handled by dais. They need proper medical attention and so the state government needs to establish centres which will be able to deal with complicated deliveries. That must be the thrust area of the future.” Dr Laxmi Sehgal, former freedom fighter and well-known gynaecologist, who runs her own private clinic in Kanpur, is appalled by the state government’s neglect of training for dais. “In Kanpur, the state government has not trained dais for the last two years claiming they no longer have the finances. Dais have an important role to play and it is better to have trained dais interacting with the village women rather than leaving them at the mercy of quacks.” Bhonwal admits that his department receives Rs 500 crore a year to promote various family health programmes. He denies the use of the ‘target approach’ by ANMs, insisting that the sterilisation target for 2003 was 10 lakh for Uttar Pradesh, whereas the DFHW had achieved a much lower figure. Bhonwal lists two key steps that need to be taken in order to turn the situation around. “We need to hire 200,000 ANMs and train an equal number of Primary Health Centres. We also need to hire and train another 200,000 dais and are waiting for government approval to recruit on such a large scale,” he says. The DHFW has also recently introduced an audit system to ascertain the reasons for the inordinately large number of women dying during childbirth. The DFHW has also set up a committee comprising members of panchayats, ANMs, doctors and chief medical officers to scrutinise all deaths that occur before, during and after childbirth. All district hospitals will have to upgrade their operation theatres in order to be able to deal with emergency cases and complications, for which an additional Rs 10 lakh is being allocated for each hospital. While the findings of this committee will be reviewed every fortnight, the findings of the state-level committee will be reviewed every three months according to a recent department directive. Meanwhile, the situation on the ground continues to be tragic. Twenty-six-year-old Somari, mother of two, lived in Nikrika village in Mirzapur district. Her husband is a poor dalit labourer. During her third pregnancy, Somari stayed in close touch with local ANM Kusum Singh and the local dai. While Kusum Singh gave her two tetanus injections and regular doses of iron right through her pregnancy, Basanti, along with other women from the community, assisted her during the delivery, on July 26 2003. On August 2, Somari developed severe cramps in her legs and was taken to a private clinic where the doctor on duty put her on an intravenous drip. But her condition steadily deteriorated and she was taken to a primary healthcare centre in nearby Rajgarh. The doctor on duty there refused to attend to her, insisting that she be taken to Robertsganj. No doctor was willing to attend to her in Robertsganj and Somari was driven to a private nursing clinic in Mirzapur. At Mirzapur, Dr Meena Jain, the person in charge of the clinic, insisted she be taken to Allahabad. By this time Somari was finding it difficult to breathe. Deciding against moving her again, Somari’s husband Adit Maurya took her to a relative’s house where she died. Sitting outside his mud house in Nikrika, Adit Maurya, a daily-wage labourer, says: “We were turned away by all those doctors because we looked so poor. Do you think they could not have saved my wife’s life? Now I have to bring up three children on my own and also earn a living as a labourer.” Basanti points out that primary healthcare centres are ill-equipped to deal with complicated cases. Another local dai asks: “Doctors and ANMs are seldom present and most of their medicines are sold to local chemists at huge profits. An ANM receives a salary of almost Rs 14,000 per month. How come they are never held accountable for anything, whereas we are being questioned all the time?” Yashodra Dasgupta, director of the Lucknow-based NGO Sahyog, confirms this. “The ANMs are fudging figures all the time. They are supposed to be inserting IUDs and giving pills but most of the time, when we go out on field visits, we find they are seldom at their posts. They receive their salaries and cannot care less about their patients.” National Family Health Survey statistics for Uttar Pradesh indicate that around one-fourth of all women receive no trained assistance during childbirth; only one-tenth of the population uses public healthcare services. This clearly indicates that a huge majority of people are being forced to seek help from quacks and hakims. As a result, thousands of women end up losing their lives. And the irony is that the women die not from lack of healthcare services but because of them. (Rashme Sehgal is a Delhi-based freelance journalist) InfoChange News & Features, May 2004
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