September 23, 2016

Chronicles of Deaths Foretold:Part 1 - Experiences from the field

Sunita Devi (name changed) breathed last in a district hospital in Godda district of Jharkhand while delivering her baby. Devi was 28 year-old and died due to absence of blood in the hospital. She was already delayed in reaching the hospital as her family took time in arranging money for the ambulance.

The family had to mourn two deaths as her child too was still born. The family also had a debt of Rs 15,000 by the end of entire affair.

“Such experiences discourage people from going back to the public health system. If a woman delivers her first child in a health facility, she resists going through the same experience for future deliveries,” said Jiban, an activist from Odisha.

Devi’s story is one of the 20 from Jharkhand that have been documented in the report “Chronicles of Deaths Foretold,” released 19th August, 2016 in Delhi. Like her, most of the women died of heavy bleeding. Either there was no provision of blood in the hospital, or they were asked to pay a hefty sum of Rs 2000-3000 per bottle. By the time families from economically weaker sections arranged for the money, women were dead.

Prepared by the National Alliance for Maternal Health and Human Rights (NAMHHR), the report documents in details the events that led to 139 maternal deaths in seven districts of four states of India – Jharkhand, Odisha, Uttar Pradesh and West Bengal. All these women are from marginalised communities. Study areas like Godda in Jharkhand or Mayurbhanj in Orissa are tribal dominated, Murshidabad and Malda and West Bengal have poor Muslim populations whilst in Azamgarh, Banda and Mirzapur in Uttar Pradesh, most women who died were from either Dalit or OBC or Muslim backgrounds.

The aim of the report was not to look at medical reasons of death – which are usually recorded as heart attacks. The aim was to find causes that led to delays in their treatment that ultimately resulted in their deaths.

The narratives show that women are going to health facilities, but the health facilities are not equipped to handle emergency cases, leading to colossal number of deaths. This situation is different than what existed a decade ago when pregnant women were seen as not seeking services of a health facility.

Lack of blood transfusion facility, disruptive ambulance services, lack of empathy from staff and unavailability of doctors are reversing the trend, as is evident from data on Janani Suraksha Yojana.

According to an analysis by Centre for Budget and Governance Accountability (CBGA), there has been a steep decline in JSY beneficiaries in the last five years. Devi’s home-state saw a decline of as much as 35.4% from 2010-11 to 2014-15. While in 2010-11, JSY was used by 386354 for pregnancy related services, by 2014-15, only 249455 women were using it. Women in other states are also rejecting the model.  In West Bengal, the decrease has been of 37.1%, in Odisha 6.6% and in Uttar Pradesh it has been 0.7%.

Experiences from the field, as captured by the report, show that public health facilities are equipped to deal only with routine check-ups and deliveries. They are unable to manage emergency situations. To begin with, high-risk women are not even picked up by the health system to take care of during delivery. Devi was aneamic and weak. Her weight was lower than required of a pregnant woman. She had delivered five children before. All these were clear signs of her being high risk. But still, not only the health system did not register her as someone who needs special attention, but could not treat her when she reached the district hospital, with meager support from neighbouring primary health centre (PHC)and Community Health Centre (CHC).

Devi died of heavy bleeding. The child had probably died even before reaching the hospital

In another case in UP, a woman was referred to a CHC by the PHC. The nurse at CHC realised that she needed to be taken to District Hospital (DH). But the woman had to wait till next morning for the doctor to arrive for referral to the DH. By the time doctor at CHC arrived, she had died, leaving her unborn child also dead.

“These are common stories in Azamgarh in UP. Government officials keep saying that there are no maternal deaths, but our experience and data show otherwise,” said Rajdev, who conducted the study in Azamgarh, UP. He was speaking at the national consultation organized during the launch of the report.

Health activists and experts showed their frustration saying that things have not moved in the right direction despite presence of so many schemes, programmes and incentives.

“It is the government’s duty to conduct maternal death reviews (MDR). As civil society, we can only tell them “how to,” said Abhijit Das, director, Centre for Health and Social Justice.

The government is not regular in conducting MDR. Even when it does, data is not made public. There is no analysis based on the reviews to improve or change the situation.

“We need to realize that a pregnancy is not a disease. It is something that can be managed and we all know it is simple. Unfortunately, in the lack of political will, saving women has emerged as a big public health issue,” said senior journalist T K Rajalakshmi, who works with fortnightly Frontline.

Jashodhara Dasgupta from Sahayog, the nodal organization which conducted the study, said, “The report is titled such because the formula of institutional delivery has not worked. Women reached the hospital as soon as they realised that they need care, but the hospitals failed them as they were not ready with the required facilities. Thus, scripts of their deaths were written while drafting policy and their deaths were foretold."

The report also shows that Janani Shishu Suraksha Karyakram (JSSK) --  entitlement to free maternal health services -- does not work at the point of delivery. Violations have been reported from every state from where the case studies have been collected. Often women’s families have had to arrange money for ambulance and expected expenses on diagnostics, medicines, supplies and in some cases informal payments, which led to delay in reaching healthcare facilities. For poor families this is catastrophic and discourages them from going to hospitals the next time.

Failure of the health system in providing something as simple as contraceptive services and counseling kept cropping up time and again in all the regions. A 40-year-old woman in Banda district of UP died during her 12th pregnancy. She had 10 live births and went for induced abortion by consuming pills for the 11th time. As the 12th pregnancy was also unwanted, she went for abortion by similar method. The woman consumed five pills without any proper medical advice. She died in less than 24-hours due to heavy bleeding. Despite reaching a public hospital, she could not be saved.

The public health system is clearly not reaching women for guidance on contraceptives. It is then doubly failing them by not providing access to safe abortion services, even after, like in the present case, they have previous record of abortions. The State’s neglect is responsible for innumerable deaths and morbidity. Behavioural issues of healthcare staff in public health facilities were faced by majority of families interviewed. Coming from marginalized backgrounds, they are not treated as equals by the government staff and this discouraged many women from seeking care in public health facilities.

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