Janani Suraksha – An unfulfilled promise

Barwani is a small district in the South-western corner of Madhya Pradesh, where it abuts Maharashtra. It has been a district since 1998, being earlier part of West Nimar or Khargone district. Before independence it was a princely state and the remnants of the princely state are visible as the incongruous Ranjeeth Club in the middle of the city. Barwani is a small sleepy town with little claim to fame, and my visit to this place was occasioned by reports coming to us earlier in the year that an exceptional number of maternal deaths were taking place at the district hospital there, and the local people had protested. As many of you may know the Government of India is currently obsessed with the issue of maternal deaths and has launched a large scheme – Janani Suraksha Yojana to reduce maternal deaths. I was part of a small team of public health experts trying to understand the reasons behind these deaths and if they indicated any kind of systems failure.

The barren landscape of Barwani

We left Indore early in the morning and drove down the Indore Mumbai highway. At one point we left the highway and took a smaller road to Badwani. The landscape changed drastically. The golden fields of wheat waiting to be harvested were replaced by the barren Satpura hills. We drove through miles upon miles of barren hill slopes with little or no tree cover. We drove across the Narmada, and were told that the Narmada Bachao Andolan was once active in the district. Three and a half hours after starting from Indore we reached the small hotel which was to be our base in Barwani. We were told that a famous Jain pilgrimage called Bawangaja was close by and that it had a huge statue of Mahavira etched on the mountain side. Unfortunately we didn’t get to see it and instead focused on our immediate task of trying to understand the health system and the reasons behind the maternal deaths.

We met with a large group of villagers at Piparkund near Bokrata Primary Health Centre in Pati Block. The site of the meeting was under the shade of a few large mango and peepul trees which grew by the side of a stream – Piparkund. The Barela tribals who lived in this region were part of a people’s organization Jagrit Adivasi Dalit Sangathan and they had become perturbed by these maternal deaths at the district hospital. Matters had come to head when one woman Vyapari Bai, whose mother and mother in law were both ASHAs ( village health worker – known as Accredited Social Health Activist), died at the Barwani District Hospital. On being asked for reasons behind her death, the district authorities hadn’t been forthcoming. This led to the villagers coming in large numbers and holding a peaceful rally outside the district hospital. Instead of meeting them and addressing their concerns the district authorities arrested a few of their leaders on charges of disturbing peace and using a microphone within a hospital compound!

Two male midwives

In Badwani I came face to face with the grassroots level implementation of a successful programme initiative – and what I saw reminded me so much of my previous experiences in Uttar Pradesh. “The more things change the more they remain the same !”

Over the last five years the Government of India has been ‘successfully’ implementing the Janani Suraksha Yojana or the maternal health safety programme. Under this programme all women from the poorer states of the country are given an incentive of one thousand four hundred rupees to come and deliver their babies in government mandated ‘institutions’. The idea is that at these institutions a trained provider will be available and if necessary quick referral will be provided to higher centres for emergency obstetric care. Madhya Pradesh has been a star performer in this scheme and was recently awarded a trophy for its achievements under the National Rural Health Mission. Barwani is a secluded district, but surprisingly according to the state Health Management Information systems many of its health related parameters are better than the state average.

Earlier all Barela women delivered at home. Here there was also a tradition of male birth attendants. We met two such male birth attendants in our meeting. From our discussions it emerged that now the villagers are very keen that the pregnant women receive the necessary services for safe pregnancy and childbirth. On many occasions the villagers have gone and asked the local nurse (Auxillary Nurse Midwife or ANM) to come and provide antenatal care at the village. On other occasions they have taken the pregnant women to the Primary Health Center at Bokrata. Unfortunately while the Barela communities in these villages have made changes in their expectations and health seeking behaviours, supported by the cash incentive from Janani Suraksha Yojana, the government services seemed careless, almost callous, in addressing these changed expectations. The same government which proudly counts the numbers of ‘institutional deliveries conducted’ at various national and international fora, was pathetically underprepared to provide the same services. The Bokrata Primary Health Centre was the first port of call for many villages in the region we visited. Unfortunately the labor room in this PHC appeared unused for a long time. The records revealed that almost all the recent deliveries noted in the PHC records had been ‘born on the way’. This seemed a unique response to support the anxious bureaucracies’ efforts to get all pregnant women to have an institutional delivery. We found that in the last 10 days 18 women had delivered in the PHC according to the records, fifteen had delivered on the way and three had been referred. Effectively no infant had been born at this government mandated ‘institution’ which we later found contributed about 50 – 60 institutional deliveries each month to the district records.

I found an even more interesting practice of meeting the MDG goal of 100 percent skilled attendance at birth by 2015 on examining the health records. Pati is one block in Barwani district and even though it is classified as remote and inaccessible it provides very impressive statistics for maternal health services. For the month of January 2011 it was noted that there were 295 deliveries in the block, of which 123 were delivered by skilled birth attendants at home, and 172 were delivered in public institutions. There were no complicated deliveries or caesarian sections for the women who had delivered during the month. There were 8 still births and 261 new born infants had been weighed at birth, none of whom were below 2.5 kg in weight and all had been breast fed within an hour of birth.  If this were true then Pati block would be among the best places in the world for any expecting Barela woman to be in, but unfortunately this official ‘data’ was a dangerous ‘fairy tale’.

PHC records showing 'born in the way'

On asking the block officials we learnt that they were not certain about who is qualified to be called a ‘Skilled Birth Attendant’ and were noting all traditional birth attendant deliveries as SBA deliveries, which they clearly are not. I personally have no issue with traditional birth attendants and consider them an important resource, but today they are untouchables in the policy arena. So here was a situation where about 50 of the 172 odd institutional deliveries were certainly not taking place in institutions and 123 of the 123 home deliveries were not being attended by so call skilled attendants. Thus the 100 percent safe delivery record of the district was at least doubtful by half ( ie. 173/ 295).

An even more interesting picture emerged when we visited the District Hospital. Barwani District Hospital works round the clock delivering maternal health services ( unlike the PHC and CHC we visited during our trip). Its workload in terms of deliveries conducted is close to 600 deliveries a month. This is a three fold increase since the Janani Suraksha Yojana incentives were announced. Unfortunately not much has increased in terms of the hospital’s capacity to serve this additional workload. Of the three gynaecologists who are posted here, two are busy half the week conducting female sterilization camps all over the district of Barwani and also in neighbouring districts as well. One of the star performers we met had conducted over 13,000 laparoscopic tubectomy operations last year. On asking her whether she felt that this huge load could actually be leading to violation of surgical norms, she pleaded helplessness in the face of government pressure to meet sterilization targets. To add to this shortage of doctors, there was only one nurse and one ayah/dai on duty for two of the three shifts during the 24 hour duty cycle. These two women are managing the labour room and a 60 bedded hospital with post operative, post partum women. Clearly the nurse is extremely busy attending to the patients needs, managing the IV drips, giving injections and medicines according to the prescribed schedules and so on. So who manages the delivery in the district hospital labour room? It did not require genius to find out that all the 15 ‘normal’ deliveries that had taken place in the last 24 hours had been conducted by a dai. Even in a district hospital the women of Barwani were not being delivered by a skilled birth attendant – the minimum ‘official’ condition for achieving safe motherhood.

While we had the privilege to see the micro level reality of the safe motherhood programme in one district of the country, the juggernaut of the Janani Suraksha Yojana continues to roll on. Every one whose life is not touched by the risks of an obstetric emergency which could need the support of this scheme, has declared it a success. Meanwhile the poor in our country continue to come to public institutions attracted by the cash incentive. The story of the many women who suffer afterwards, dies in the din of a self congratulatory applause of policy makers, donors, health managers and even nurses and paramedics. It is unfortunate but it may need many more and louder protests from the poor, like the one at Barwani before the system concerned will be able to hear them and take note.