Burden of birth
Urvi Devi, 20, was in her ninth month of pregnancy. She woke up one night to urinate. Since there was no toilet in her home, in Madhopur village in Patna’s Maner block, she went to a nearby field accompanied by her husband. It was then she went into labour. With her nervous husband holding her, Urvi delivered a baby in the darkness and fainted soon after. Her husband, who was shocked at the sudden course of events, realised then that the baby did not cry. Urvi had given birth to a stillborn child.
Neighbours gathered as her husband cried for help. But everyone was clueless about how to take the unconscious mother to the primary health centre (PHC). The nearest PHC was 12 km from the village. It was late and no ambulance was available. The night passed without Urvi receiving medical attention. In the morning, she was rushed to a nearby private nursing home. There, she was referred to the Patna Medical College and Hospital (PMCH), a premier government hospital. Urvi died on the way.
Urvi’s is not the lone case of maternal deaths in Bihar. Kiran Devi, 21, was known as the “iron lady” in her in-laws’ home. On November 12, 2013, when she went into labour, her mother-in-law, Dulari Devi, could not arrange transport to take her to the hospital. Kiran decided to walk to the nearest private clinic 5 km away. She managed to reach and delivered a healthy baby, but because of excessive bleeding died the next day.
None of these deaths was recorded in any PHC or hospital. The Bihar State Health Society (BSHS) claims that the state has witnessed a decline in the maternal mortality ratio (MMR) from 371 deaths per 100,000 births during 2003- 2005 to 261 deaths during 2007-2009 (see “Maternal mortality ratio in Bihar over the years”). This was higher than the all-India average of 212, according to the March 2012 RHS Bulletin, a report on the rural healthcare system published by the Ministry of Health and Family Welfare. While the government claims a decreasing trend in MMR cases in the state, the ground reality paints a different picture.
A Patna-based non-profit, Centre for Health And Resource Management (CHARM), conducted a survey in Maner and Phulwari Sharif blocks of Patna during 2012-2013 to gather information on maternal deaths. On the basis of the data collected, it ascertains that there have been 20 cases of unreported maternal deaths in 11 panchayats of these two blocks alone during the same period. CHARM members and Right To Information (RTI) activists believe maternal deaths go unnoticed because they are not recorded, and claim MMR figures quoted by the state are unreliable.
Health workers wary of blame
Under the National Rural Health Mission initiated by the Ministry of Health and Family Welfare, Accredited Social Health Activists (ASHA) are appointed in rural areas as community health workers. They act as the contact source between the people and PHCs. ASHA workers and Auxilliary Nurse Midwives (ANMs) are required to notify the block-level officer about maternal deaths. But they are wary of reporting as they do not want to take the blame fearing departmental action. These workers attribute the high MMR in the state to poor healthcare infrastructure, including ambulance services, inadequate PHCs and staff, lack of trust in their functioning, anaemia in pregnant women, lack of connecting roads and the mushrooming of quacks.
“In the absence of adequate PHCs in villages, pregnant women are forced to take the help of quacks for delivery, who only complicate the matter because they are unskilled. Once the situation becomes dangerous, the quacks refer them to PHCs. We can’t do much in complicated cases and so refer them to hospitals,” says Madhavi Kumari, an ANM at the Gaunpura PHC in Phulwari Sharif. She explains that people do not trust government-run PHCs. “Patients come to a PHC to get treated for minor ailments. When a pregnant woman dies, her family usually blames us,” she adds.
Dismal health services
The woeful condition of health services in Bihar is highlighted by the RHS Bulletin. It shows there are 1,863 PHCs in the state against the required 3,083, while community health centres face a shortfall of 700. When it comes to staff, the number of female health assistants in PHCs stands at 358 against the required 1,863.
Premier hospitals fare no better. In response to an RTI petition filed by social activist Raj Hans Bansal, PMCH admitted there are only 10 beds in its premises for deliveries and there have been 776 maternal deaths in the past five years. On the other hand, the prestigious Indira Gandhi Institute of Medical Science in Patna has had no case of birth in the past two-and-half years. The hospital authorities attribute it to the absence of a labour room, which was built only in December 2013.
Who is responsible?
It is not only the health workers who hesitate to report maternal deaths. In many cases, the victim’s family, especially in-laws, tries to downplay the death for fear of being implicated in a dowry case. Dulari Devi boils with rage when asked about Kiran’s death. “Why are you interested in her death and not in the baby who survived?” she fumes.
Urvi’s family refuses to be photographed. When this Down To Earth reporter wanted to speak to her husband, the family members refused to even divulge his name fearing he might be framed in a dowry case.
Loopholes exist at the administrative level too. According to the Maternal Death Review guidelines, every district magistrate is required to hold a monthly review meeting on MMR, which is to be attended by health workers in the presence of the victims’ family. This practice is largely ignored in the state.
Another reason for lack of proper government records is inaccurate assessment of MMR cases. Ghanshyam Sethi, health officer working with UNICEF in Patna, says the Sample Registration Survey (SRS) calculates MMR through random surveys in villages. The data is not reliable since neither are the families willing to talk about the deaths nor are they recorded with the PHCs.
In April this year, BSHS issued a notification announcing that a health worker or officer in the state will get Rs 250 for each reported case of maternal death. “No departmental action or proceedings will be initiated against the health workers; instead, the government will pay them for reporting such deaths,” says Gaurav Kumar, deputy director, Maternal and Child Health Bureau. Health workers have welcomed the move. “We are contractual employees. Financial incentive will boost our morale,” Madhavi says.
Meanwhile, UNICEF has started an awareness and training programme in the two districts of Gaya and Purnia to encourage reporting on maternal and infant deaths. The effort involves the community, ANMs, ASHA workers and heads of PHCs.