8 rch - pratichi

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In spite of numerous attempts by the Govetnment of India and other agencies

to imptove maternal and child health, the overall achievements are still far from

encouraging. Many different variations - regional and socio-economic - are found in

the achievement of goals. Kerala, contrasting sharply with Bihar andTJttar Pradesh,has shown remarkable achievements in the field of reproductive and child health -

comparable o the developedcountries.3Ag^in, people belonging to the upper socio-

economic strata were found to exist in a much better condition (not only in terms of

maternal and child health but also in terms of general health status) than the rest of

the populauon.a

Our study chiefly aims to examine the delivery of basic health services - both

general and reproductive - in order to find the linkages between service delivery andits impact. In this ,sectionrr,'eshall discuss the reproductive and child healtrhservices

made avatfable o people in the study areas.

Studies like the NSS and NFHS II, whilst finding some improvements, have

detected many weaknesses and suggested larger areasfor futher improvement to

achieve the optimum level of reproductive and child health. In agreement vzith the

broader studies, our rnquiry points out some micro level details of the problems

concerning the services of reproductive and child health.Our study shows that despite many different claims regarding the achievements

in reproductive and child health, there is a long v/ay to go to make these services

avatlable for all, particulady in the rural areas.The study did not have much scope

for examining the different aspectsof reproductive and child health. We emphasised

the delivery of health servicesand shall accordingly discuss some of the issuesper-

taining to reproductive and child health.

C r ! r r - D s r n r F l

An important component of the reproductive and child health programme is to

encourage safe delivery under trained supervision, and under hygienic conditions.

Our findings in this regatd are worrying.

Fifty-three percent of the deliveries of the youngest living children of mothers

in Birbhurn took place at home; in the case of Dumka this was 94 percent. In both

the districts alarge number of respondents (70 percerrt in the caseof Birbhum and

53 percent in the case of Dumka) felt that it was not necessaryto take pregnaflt

women to hospitals, as, traditionally, childbirth takes place at home. As we shall see

in section 8, the poor functioning of the sub centres, PHCs and hospitals, the low

levels of awareness and poor ser'u-ice elivery of other programmes like antenatal

care and immunizatio{t, ate rampant.

In addition, the poor infrastructural facilities avajtTablen the public health centres,

their distance to the villages and the costs nvolved in child deliveriesoutside the home

confined people to their traditiona-l sphere. For example, in Dumka the facilities for



found only five mothers who gave birth in hospitals, of whom four gave birth in pri-

vate hospitals and only one in a public hospital. Many of the respondents of Dumka

said that glviflg birth in a hospital was \,'ery expensive and thus not widespread.

The distance ftom place of residence to the hospital played a maiot role indetermining the place of birth. Only 21 of tfie PHCss of Birbhum (out of 77 -

including BPHCO have childbirth facilities. Of a total of 27 rr:'orherswho gave birth

to children in hospitals in Birbhum, 52 percent went to public hospitals, 37 percent

to nursing homes and only 11 percent delivered their children in the PHCs. Such a

situation has created the demand among a maioity of respondents in both the dis-tricts for childbirth faci-lities at the PHC level in order to faclhtate the ability of

mothers to avail of setvices at an accessible ocation.

Howeveq we find a sharp contrast between Birbhum and Dumka with tegard to

institutional deliveries. Despite many difficulties, the relatively superior operational

status of the public health system n Birbhum could attractalarger number of moth-

ers to institutions for their deliveries.

The lack of transport facilities was reported to be a maior ptoblem hindering

childbirth at hospitals. This was particulady serious in the villages of Dumka, though

many residents of Birbhum villages were also found to suffet from this problem.

Family members of a ptegnant woman of Boro Sangra village were initially

reluctant to take her to the hospital, given the problem of transportation. Finally she

was taken to Purnadarpur hospital by trolley (a three wheeled manual-poweted cat-

riage, the only means of transportation in many villages) following persistent labour

pain for many hours. The ch,ild was born on the trolley, but the mothet's condition

worsened. After admission to the hospital, it took her about two weeks to recover.

In the meanwhile her family had to spend a huge sum of money for related exPens-

es - Rs. 5,000 - which they borrowed.

Assistance in child birth: A woman reported in a frustrated voice "amaderDaibha/0,

garib manusherhaspatalebhorti hoa maron,Bed, osudsab kena, tar upar daktar-nurseder ato

katha - \7e poor people ate better off with the village Dai. Gong to hospital is very

expensive and cumbersome>we have to pay for the bed and medicines. In addition,

the doctors and nurses treat [us] in a harsh manner".

Ninety-four percent of the deliveries in Dumka reportedly took place at home.



understatement in the reportage of complications during childbirth. In factcases ofsepticaemia, incessant bleeding, etc. were considerecl quite normal. The types ofcomplications that (mainly literate) mothers reported were:

r Prolonged labour

r Delayed expulsion of placenta

r Excessive bleeding

r Int-ections

I Weakness

Complarnts were made in some cases hat the hospital staff did not pay adequateattention to their complications. A heart-rending story was narrated by a grief-strick-en mother of Birbhum who lost her son of 18daysdue to the negligenceof the hos-pital staff. It was a complicated case.The mother was unconscious after the deJivery

at the hospital. The nurse did not tie theumbilical cord propedy and the subsequentincessant bleeding combined with the carelessnessof the hospital staff took the life

of the child. The mother believed that becauseof their poor economic background,the hospital staff did not bother to look aftet the child. They did not even feel sorrvfor the tragedy.

Cost involvement in childbirth: A majority of our respondents (especiallyeldedypeople at Birbhum)

remembered that eadier thepHCs

had been equipped with someindoor facilities and the rural poot used to get treatment fiee of cost. Mothers admit-

ted to the PHCs or hospitals for childbirth, they remembered, used to get nutritiousfood. But nowadays,many respondentssaid,childbirth has become an expensiveaffair.

The anticipation of higl-rexpenditures to be incurred at hospitals was an obvi-

ous reason for not using hospital services for childbirth. While the averagecosr perchildbirth was found to be Rs. 372 ]n Birbhum and Rs 250 in Dumka, the cost

involved in conducting home deliveries was much lou,er. In Birbhum expensesonhome deliveries was found to be Rs 150 and in Dumka it averaged Rs 99 per case.

_ In the caseof deliveries conducted at public and private hospitals, the differen-

tials in the expenditures incurred were much higher. In Birbhum,

the average expenditure on childbirth in pubJic hospitals was Rs 969

and in Dumka it was much higher - Rs 1,900.In rhe caseof private

hospitals or nursing homes the figures for Birbhum and Dumka

were Rs 2,200 and Rs 1,875 respectively.The cost differentials during childbirth point to the existing

social differences in terms of affordability, awarenessand function-

ing of the public health system. $(4rile the other caste or higher

castepeoiiie of Birbhum incurred more expenditure on childbirth

(Rs 694 an average)people of the SC and ST communities spent

much less (Rs 255 and Rs 233 tespectively) or childbirth-related

expenses. Similady, while expenditure incurred on childbirth byother castes n Dumka was Rs 638, the figures for the SCs and STs

were Rs. 259 and Rs 191, respectively. AIso noteworthy is that a

Chart 6.1 Expenditure on Childbirth

n

Tnrt /llr.t \

Inst. ?ub.)

Home

0 1000 2000 3000

AmountS.S)



Chatt 6.2

How many got iron & folic acid tablets

large part of the expenditure on childbirth was incurred on payments made to birth

assistants.Actual expenditure on-nutrition, medicine, etc. was found to be negligible.

Many families, in both districts, who earn their livelihood ftom daily wage

labour, complained that they had become indebted to meet expenditures on child-

birth, particulady in caseswhere pregnant women had to be shifted to hospitals. The

patients felt themselves to be completely at the mercy of doctors and even in the

case of notmal delivedes, doctors were seerr o prescribe a long list of medicines,

many of which medical experts themselves termed classic examples of drug abuse.

Attendants and other staff reportedly extorted money from the relatives of women

admitted o hospital.

Chandana,a woman from Birbhum district, was taken to hospital for childbirth.

The family had neither enough money with them nor the time required to get the

BPL (Below Poverty Line)6 certificate from the Panchayatto avaiof free healthcare.

The attending doctor gave^ long Jistof medicines'to the famtly members to procure

immediately from the matket. Since they did not have any savings they mortgaged

some utensils and ornaments and borrowed money at a high rate of interest - ten

pefcent per month or 120 pef cent per annum!

P nr i i . tn rucyR tL r r t ' r ) ( . - t t ! ' t

, Institutional delivedes are direcdy linked to regular antenatt). care as health work-ers n rural ^reas are supposed to motivate women to undertake institutional deliveries.

Antenatal care refers to pregnancy related health care provided by a doctor or a

health worker in a medical institution or at home. The reproductive and child health

programme prescribes that women must receive two dosesof tetanus toxoid vaccine,

adequateamounts of iton and folic acid tablets and at leastthree antenatalcheck ups

that include blood pressure checks and other procedures to detect pregnancy-relat-

ed complications.tThe reference period for this data was the two years preceding our study visits. As

regards preventive services, pregnant women in Birbhum have teportedly received

more benefits than have their Dumka counterparts. V4tile in Birbhum 46

percent of the women Q6 out of 5Q repottedly received ron and folic acid

tablets, the figure for Dumka was only 27 percent Q2 out of B2).

In response to a question as to whether pregnant womefi received

adequate quantities of iron and folic acid tablets, 77 percent (of those

who received these tablets) in Birbhum replied in the affirmative while the

figure for Dumka was much lower - only 36 percent. Some respondents

in Dumka teported having purchased iron and folic acid tablets from the

market. Interestingiy, a doctor in a PHC said that they possessedadequate

stocks of such medicines but these could not be made avatlableto the

women due to shortage of staff! He also bemoaned that rural women

were reluctant to consume iron and folic acid tablets.

80

E n oq

b 4 0

20

UDon't

knorr.'



Almost 70 percent (40 out of 5| of the eligible women in Birbhum

said that they had receivedat leastone tetanus oxoid injection during

pregnancy but in the case of Dumka the figure was extremely low -

only 26 percent QI out of 82). Some of the mothers in Dumka told us

that they had had to pay a sum of Rs 30 to be administered tetanus tox-

oid injections from private clinics. As regards the number of tetanustoxoid inject ions, only 45 percent of the total number of respondents

(40) in Birbhum who had received a dose of the TT iniection during

pregnancy reported havrng received all the required doses. In Dumka

the figure was even less - only 33 percent of a total of 21 mothers.

S(/ecame across a number of cases of young mothers in Dumka

who had never visited a doctor during the entire period of their preg-

nancy. Antenatal pregnancy check ups had a correlation with the litera-cy level among women, while a related consideration was the reported high financial

outlay required for doctor visits. Many female respondents earned theit living and

simultaneously managed their household chores. Going to see a doctor meant losing

a day'swork, which seemedalmost unaffordable. However in Birbhum most $/omefl,

particulady from the other castes, eportedly visited doctors - mainly private ones -

at least once during pregnancy. An eldedy woman in Birbhum commented depre-

catingly, "Ekhon da masherpoatihaleodaktarer kachhechhwtchhe,mad.eramoiosabchilo na.(I.{owadays even two months' pregnant women are rushing to doctors but in our

time we never did such things.)" Howevet, the cases of the tribal women and many

women of the scheduled castes n Birbhum were not found to be very different from

the situation obtaining in Dumka.

P c s r - l r A T A L A t i F

The health of a mother and her newborn child depends not only on the health

care she rbceives during pregnancy and childbirth but also on the health care she and

her baby receive during the first few weeks after delivety. Postpartum check ups with-

in two months after delivery are parttctiarly important for non-institutional births.

Recognising the importance of postpartum check ups the Reproductive and

Child Health Ptogramme strongly tecommends three postpartum visits.SThe Rapid Household Survey, for both West Bengal and Jharkhand, found that

very few women actually teceive postnatal check-ups (32 percent for \)flest Bengal

and 14 percent for Jharkhand)-9 Our findings also do not show a better picture.

Assistanceby health professionals s an inseparablepatt of the postnatal check

up. This requires thorough and regular contact between the women and the health

workers.

Although the postparrum check-up is a priority item in the ioblist

ofANMs in

both districts, n reality a negJigiblenumber of women reported having been visited by

the ANMs after chjldbfuth, let alone getting any assistance.A few of the committed

Chart 6.3

How many got tetanus injections

BO

- 6 0

9 4 U

r l 2 0

0

lff iDumka ]

Don't

know

8 rch - pratichi

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