Towards an Appropriate Maternal Health Strategy
The road to providing holistic care to the rural poor successfully is long and arduous and has many cross-roads. This narrative describes one of the first cross-roads on this journey and relates to the evolution of maternal health services starting in 1981 as part of the Jowar Health Assurance programme. The narratives drive home the reality that a vast difference exists between availability and accessibility of health services to the poor living in rural communities. The success of the initiative is borne by the fact that the last maternal mortality to occur at home or on the way to the hospital occurred in 1985.
The Journey begins…
The Village Assurance programme took root in the villages surrounding Sevagram starting in 1979.
Dr Jajoo reflects back and remembers “It was the year 1979, when we vowed to take health services to the village people. So as to provide doorstep maternal services as a top priority we aimed to enlist expectant mothers, detect pregnancy early, and identify local support for home delivery. Using the identified local support as a link-worker during timely regular monthly antenatal visits, we hoped to identify mothers-at-risk and supervise their hospitalization.”
Several events along the way however, were to shape the future destiny of this programme.
Dr Jajoo remembers “The year was 1981. One eventful day, a pregnant woman was brought to the emergency room at Kasturba Hospital, Sevagram from one of the villages covered by the Village Health Assurance scheme. She was in a state of shock from post-delivery bleeding by the time she reached the hospital. She had travelled for two hours on a bullock-cart from her village 10 kilometers (6.2 miles) away!
“As part of the Village Health Insurance scheme coverage, we had registered her early in the course of her pregnancy on one of the outreach visit. A home delivery by a dai was suggested, based on her history of uncomplicated previous delivery. She delivered a healthy girl at home, but retained her placenta, thus causing profuse life-threatening bleeding.”
“We faced the full wrath of the mother-in-law who had insisted on a hospital delivery during one of the prenatal visits and for putting her daughter-in-law's life in peril.” Her question “Will you let your wife deliver in a village by the hands of a totally unsupported dai?” This brought home the message that giving birth to a child is virtually a second life for a woman and every woman had the right for a safe motherhood in a welfare state. Three units of blood transfusion and emergency surgical intervention ultimately, saved her life!
“One fateful day in 1983, a woman was brought from a village 12 kilometers away from the hospital for non-progression of labor in the wee hours of the morning. By the time she could reach Sevagram at 4 a.m., the baby was already dead.”
She had been to the hospitals maternity clinic 2 days ago and had requested for hospitalization. However, hospitalization was refused as her due date was 2 weeks later and she was not in active labor. It was felt that she could come back a week later since her village was not very far off.
However, the fateful day she went into labor it rained heavily. A dai (midwife) from a nearby village was summoned but as the delivery did not progress as expected, she had to be transported to the hospital. The 4 kilometers muddy approach road of the village would not allow even a bullock-cart to ply. The villagers ultimately lifted her makeshift bed on their shoulders and brought her to the main road. An attempt to get emergency ambulance service was undertaken from the road side village, but alas! The telephone lines were not working. They had to arrange a bullock-cart which took two hours to tread the 8 kilometers distance. By then, it was too late and the baby was dead in the mothers womb!
Prof. Jajoo remembers the woman’s cry “Who knows the need of hospitalization better, a diseased patient or an expert at ease who has never experienced labour pains?”
Roads and transport availability have a lot to do with accessibility of hospital services was the lesson learned. Doctors with urban backgrounds, unaware of the naked poverty in rural setting may not be able to understand the ground realities and empathize with the problems rural patients face on a day-to-day basis.
“By 1985, based on our experiential learning, an efficient maternity services well supported by a referral system to the central hospital was in place. We patted ourselves on our back as there was no additional maternal mortality from the catered villages participating in the Jowar Assurance scheme in past five years.”
“Alas! The honeymoon did not last long!” News came from a village barely 4 kilometers from Sevagram.
A woman was advised hospitalization during an outreach village visits as she was experiencing bleeding before child delivery. Though she nodded each time, she did not heed the given advice. Within half hour of delivering a baby at home, she bled profusely and died. This woman, though aware of the dangers of delivering at home, decided against medical advice to stay back home to cook for her family due to social and economic pressures. The husband male ego did not permit him to cook for himself or the family. The irony was that he remarried within three months of his wife’s death! ‘We were haunted by the naked realities of the social situation for this mother” says Prof.Jajoo.
“Despite making progress in the provision of maternal health care, we learnt from this incident about the social inequalities faced by a women in rural India. In this social milieu where women are considered as a dispensable, and where the birth of a female child is considered as the mother’s fault, the social dimension had to be improved. This event sowed the seed for our future attempts for social engineering as part of a holistic approach.” Refer Self Help Groups.