Lessons learnt so far
- For life saving medical services to be accessible to the poor, emergency services must be free.
- There is a vast difference between availability and accessibility of health services to the poor. Accessibility of emergency medical services within half an hour distance with good road and fast mode of transport are mandatory provisions. A culture which favors justice rather than just equality is required so as to give the poor the opportunities to access public facilities such as hospitals.
- A healthcare system for rural communities has to exist in partnership with the people Refer Jowar Assurance scheme.
- A trained dai (midwife), working in isolation, can do little and requires support of a well- knit referral system for her to be effective.
- While undertaking traditional health education programmes and health education initiatives in rural India, we had to revisit and confront many of our dogmas and beliefs.
- The compulsions that socio-economic political milieu imposes impact on the delivery of health care in a major way. A marginalized existence wherein a family cannot afford two full meals, is unable to focus on their health needs. What kinds of nutritional advice can one give to the poor pregnant mother?
The message was clear. The village folk are well aware of their problems. They do not need sermons but deserve sympathetic hearing, empathy to assimilate their life situation and then a feasible way out.
The journey continues…
As lessons were learnt from our accumulated experiences, there was a realization about the reach of every aspect of the maternal health strategy. The monthly visit by the auxiliary nurse midwife and the mobile health offered door-step preventative services and helped identify at-risk pregnancies. The supplementation of iron, folic acid, calcium can be safely entrusted to village dai’s.
A visit to the hospital during late pregnancy was suggested to the villagers as being vital for the maternal child wellbeing. This hospital visit was necessary to provide immunization for the pregnant mother and to diagnose many medical conditions (like the diagnosis of hypertensive disorder, pelvic contraction and placental position needs assessment) prior to delivery. This visit helped identify high risk pregnancies which may require early hospitalization and thus decrease maternal foetal mortality and morbidity.
We were able to the replace 'The traditional Auxillary Nurse Midwife (ANM) – based system with equally trained link worker like dai’s, who were trained and in constant contact with an alert medical service centered in the referral hospital. The dais in contrast to the ANMs, were village residents who were willing to provide peripartum services. They were paid a honorarium offered by the villagers themselves for her work.
The soul of this experiment can be summed up by a Chinese proverb.
“Go to the people
Learn from them
Live among them
Start from what they have
Build upon what they know.”
- 1981- Emphasis on delivery at home under the supervision of Dai, if there is no maternal risk factor.
- 1983- Lesson learnt – Never deny hospitalization to the pregnant lady if she demands it.
- 1985- Defined population to undergo hospital delivery with assured free hospitalization - first pregnancy, for at risk mothers, for complicated delivery / pregnancy.
- 1990 –till date – to deliver in hospital or at home is the pregnant mother’s choice.
Impact of the programme
- Almost all prefer delivery in hospital
- 1985 was the year when we registered last maternal death at home.
- With accessibility and affordability of health assurance scheme, we did not come across maternal death at home or on the way to hospital till date.
- With appropriate immunization against tetanus, no case of maternal or neonatal tetanus has been witnessed from insured villages since 1985.