On the ninth of every month, pregnant women visit the primary health centre at Wazirabad, Gurugram district, Haryana, to receive antenatal care under the Pradhan Mantri Surakshit Matritva Abhiyan (Safe Motherhood Programme)

Wazirabad, Haryana: Rajvanti Devi, 38, stood in a long queue of pregnant women, braving the bright midday sun, at a primary health centre in Wazirabad block of Gurugram district, Haryana. This queue is usual on the ninth of every month, when the health centre provides services to pregnant women, particularly those identified with high-risk pregnancies, under India’s Pradhan Mantri Surakshit Matritva Abhiyan (Prime Minister’s Safe Motherhood Programme, PMSMA).

Rajvanti Devi, a mother of two girls, was pregnant for the third time, but she did not know how far into her pregnancy she was. This was her first visit to a health centre, and she was surprised when told she was six months pregnant. Further, the pregnancy was risky, the health centre staff told her, because with a haemoglobin level of 8.8 gm/dL, she was mildly anaemic–the normal range is 12-16 gm/dL for women. The risk was greater as her second child had been born through a caesarean section.

Her pregnancy will be tracked through Haryana’s high-risk pregnancy portal–the only one run by a state government, launched in November 2017–to make sure she receives all required antenatal check-ups, supplements, and referrals to specialists in community health centres or district hospitals. Under this system, Gurugram has recorded 2,750 high-risk pregnancies, and Jhajjar district 3,526.

This is part of Haryana’s ongoing efforts to reduce its maternal mortality ratio (MMR)–past efforts have made the state’s MMR the 12th lowest in the country, having cut it down from 101 deaths per 100,000 live births in 2014-16 to 98 in 2015-17, according to Sample Registration System (SRS) data. The Indian average was 122 in 2015-17.

Haryana’s health ministry has set a target to reduce its maternal mortality ratio to 70 per 100,000 births by 2030. The high-risk pregnancy portal helps register and better track high-risk pregnancy cases, to make sure the women never miss a check-up and their progress is monitored closely.

“The goal is to reduce the maternal mortality rate, infant mortality rate and stillbirth because morbidity and mortality is particularly high in high-risk pregnant cases,” said Alka Garg, deputy director for maternal health in the National Health Mission (NHM), Haryana.

Haryana’s experience with its portal would be instructive for all Indian states, which together detected half a million women with high-risk pregnancies under PMSMA between 2016 and 2018. High-risk pregnancies have a greater possibility of complications during labour and delivery, birth defects, premature delivery, stillbirth and, in worst cases, the death of the infant and mother. “Timely detection of risk factors during pregnancy can prevent deaths due to life-threatening complications during childbirth,” PMSMA guidelines note.

As IndiaSpend’s visit to Gurugram district showed, the programme is already showing results. The proportion of high-risk cases identified during antenatal check-ups increased from 6.91% in 2013-14 to 14.35% in 2017-18, data from NHM Haryana show.

Earlier, grassroots health workers would check up on pregnant women but there was no focus on high-risk cases. Now, if a woman with a high-risk pregnancy misses her monthly check-up, it is flagged within the system, and health workers go to her house and bring her to the health centre, said Sheela Devi, 57, a health supervisor at the Wazirabad primary health centre.

The Niti Aayog identified Haryana’s policy for managing high-risk pregnancies, including the portal, as a ‘best practice’ in antenatal care in January 2018.

However, frontline workers, beneficiaries and doctors said the quality of care must be improved, and services made available not only on the ninth but throughout the month.

Tracking high-risk pregnancies

High-risk pregnancy cases include women who have severe anaemia with hemoglobin levels below 7 gm/dl, hypertensive disorder in pregnancy (with blood pressure higher than 140/90 mmHg), Human Immunodeficiency Virus (HIV) or syphilis, gestational diabetes, previous history of caesarean section, stillbirth, abortion, premature birth, obstructed labour, and twin pregnancy.

On being found to be at risk, Rajvanti Devi was given a red card signifying high-risk pregnancy, and will now be closely monitored by grassroots health workers–accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs)–along with counselling sessions and regular follow-ups until the birth of her child.

A woman detected with a high-risk pregnancy is given a red antenatal card with a ‘High Risk’ stamp. She is closely monitored through Haryana’s high-risk pregnancy portal.

The PMSMA is an expansion of the Vande Mataram programme, first launched in the early 2000s. “In the past couple of years there has been an expansion of maternal and outreach health services and more recruitment of ANMs, so things have really improved,” said Sulakshana Nandi, national joint convener of the Jan Swasthya Abhiyan, the Indian branch of the global People’s Health Movement (PHM).

More than 10 million women received antenatal care under PMSMA between July 2016 and January 2018, according to the central Ministry of Health and Family Welfare.

“All government hospitals collate data on the number of high-risk pregnancies in the district, and the portal is updated once every month with all case details,” said Neelam Chaudhari, 44, an ANM in the Islampur health centre of Haryana’s Gurugram district.

“The portal was an innovation of the state to identify high-risk pregnancy cases,” said Garg of the National Health Mission, Haryana. “We have a 100% name-based portal where each woman’s journey through her pregnancy will be closely monitored until the birth of her child.” 

Of all the high-risk pregnancy cases recorded in Gurugram, 647 were due to previous caesarean section deliveries, 179 because of severe anaemia, 187 due to hypertension and 211 due to multiple pregnancies, according to the portal.

IndiaSpend obtained district-level data for Gurugram and Jhajjar from the high-risk pregnancy portal. Haryana’s National Health Mission did not share data for the entire state despite repeated emails and phone calls in the month of October. This story will be updated if we receive the data.

Counselling

A crucial component of PMSMA is counselling of expecting mothers. “We tell them to practice spacing between births,” said Sheela Devi. “If it’s a high-risk case or a caesarean, we counsel them to at least have a gap of three years until the next baby.” 

“If at any given point they miss their monthly check-up, ASHAs are sent to their homes or we call them to find out why they didnt come,” she added. “The high-risk pregnancy portal is extremely helpful to keep a track record of every woman.” 

For delivery or conditions requiring urgent medical attention, high-risk pregnancy cases are referred to district hospitals or community health centres that provide specialist services. “Just last month on PMSMA day, we found a case of hypertension,” said Chaudhari. “A woman had 220/190 mmHg blood pressure, she was immediately sent to the civil hospital along with an ASHA worker.” 

Antenatal care

Like Rajvanti Devi, most women do not receive proper antenatal care during their pregnancy. In 2015-16, only half (51%) of the women aged 15-49 years who were surveyed had the World Health Organization-recommended four antenatal care visits for the last birth before the survey, according to data from the National Family Health Survey 4 (NFHS 4). About 17% of women received no antenatal care during pregnancy.

Not everyone agrees that the PMSMA is the ideal way to provide antenatal care. Women have to wait in queues, some of them do not get to see a doctor, and the quality of care is poor as there are many women waiting on one single day, said Nandi of the Jan Swasthya Abhiyan.

“This programme is just another campaign,” she added. “The actual high-risk cases are not being prioritised due to herding of all pregnant women on one day of the month to increase footfall… I have seen cases in which the services that should be provided everyday are not being given because the priority is to gather as many women as you can on the 9th of every month.” 

Low intake of iron and folic acid tablets

When Rajvanti Devi’s high-risk pregnancy was detected, she was recommended to get an ultrasound, and start regular doses of iron and folic acid tablets. During pregnancy, anaemia increases the risk for maternal mortality, preterm birth and infant mortality, as IndiaSpend reported in September 2019.

“I have iron tablets but I do not eat them,” said Rajvanti Devi. “It makes me feel nauseous and I can’t do any of my chores later.”

“Women do not eat the prescribed iron tablets,” said Chandan Kachroo, 58, a gynaecologist in a private hospital in Gurugram, who has volunteered to see patients one day a month under the PMSMA. “I have mostly seen this in patients coming to government hospitals. Patients in the private hospital eat the iron tablets regularly.”

Only 14.4% of the poorest women took iron and folic acid tablets for more than 100 days, as compared to 48.2% of women in the highest wealth bracket, according to data from the 2015-16 NFHS 4.

Chandan Kachroo, 58, a private gynaecologist and volunteer under the government’s safe motherhood programme, with Rajvanti Devi, 38. Her pregnancy is high-risk as she is mildly anaemic and had a caesarean section previously. Haryana tracks high-risk pregnancy cases through an online portal, the only state to do so.

Caesarean sections

Previous caesarean sections make up for a large chunk of high-risk pregnancy cases: 24% in Gurugram and 13% in Jhajjar, based on data from the high-risk pregnancy portal.

The rate of caesarean sections has doubled from 9% in 2005-06 to 17 % in 2015-16. Caesareans are particularly common in private sector health facilities (41% of deliveries), an increase from 28% in 2005-06, according to NFHS 4.

Private sector involvement 

Doctors working in the private sector are encouraged to volunteer for PMSMA and provide voluntary services at nearby government health facilities on the ninth of every month. About 5,799 such volunteer doctors have registered to participate under the programme since July 2016, according to a reply in the Lok Sabha (lower house of the parliament).

“There was an appeal made to all the gynaecologists part of the Federation of Obstetric and Gynaecological Societies of India (FOGSI) to participate in PMSMA,” said Kachroo. “I have volunteered for this scheme as a way to give back to the society.”

Kachroo examined a total of 50 patients in the four hours of her volunteering service at the primary health centre in Wazirabad. She said she found 12 cases of high-risk pregnancies.

“Maternal health services being available to every woman is a part of universal health coverage, rather than a charity, which the PMSMA makes it out to be,” said Nandi of the Jan Swasthya Abhiyan. “Remote areas do not have as many private gynaecologists. But most private gynaecologists volunteer in bigger cities where there are already enough practitioners available.”

This story was first published here on Healthcheck.

(Ali is a reporting fellow with IndiaSpend.)

Courtesy: India Spend

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Surujmuni Marandi, 24, had decided to deliver her baby at the Godda district hospital in north-eastern Jharkhand. Like many other women, she was drawn to the idea of free medical assistance, medicines, nutrition and postnatal care for poor, pregnant women promised by Janani Suraksha Yojana (JSY), the government programme aimed at reducing India’s high maternal mortality rate (MMR).

Marandi ticked all the boxes in the JSY profile of a woman who needs to be incentivised to deliver in a hospital: She was an adivasi, poor, had little access to health facilities, and would have gone for a traditional home-birth if it wasn’t for the scheme. Marandi should have had an easy time delivering her son at the hospital. But, as this documentary by activist media group Video Volunteers shows, she is denied everything that JSY promises.

Marandi, debilitated by labour pain, was made to wait six hours for a doctor who finally did not turn up for duty. She was asked to pay for medical attention and medicines and denied the nutrition and care that was her right. Denied basic facilities, even the use of a toilet, she finally delivered with the help of a nurse.

“We don’t know where the doctor is. You go, find out,” the nurse told Marandi’s mother when she asked for assistance.

Marandi’s story holds answers to India’s maternal mortality puzzle: Despite a rise in institutional deliveries, maternal mortality continues to be a worry for in India.

The number of institutional deliveries rose by 15% over the decade ending 2014, mostly aided by the JSY, according to this 2016 report by the think tank Brookings India, based on National Sample Survey Office (NSSO) data. Deliveries in government hospitals rose by 22%, fell by 8% in private hospitals and home-births dropped by 16%. But 167 women are still dying per 100,000 live births, as per latest government data. This is despite a 70% fall in MMR over a quarter of a century.

Why aren’t institutional deliveries resulting in fewer deaths during childbirth? Simply incentivizing institutional deliveries isn’t enough to push down MMR and infant mortality rate, wrote Ambrish Dongre, fellow at the Centre for Policy Research, in his 2014 analysis of the JSY. Physical and human infrastructure for maternal health and the quality of care too should improve, he said.

An IndiaSpend analysis of multiple reports and studies shows that Dongre’s analysis is right. The public health infrastructure, it appears, is simply unable to support the rising number of institutional deliveries that the government is encouraging. And this could possibly explain why India’s MMR is worse than Sri Lanka (30), Bhutan (148) and Cambodia (161) and the entire Arab world, as IndiaSpend reported in August 2016.

Painless, free care for pregnant women? Not quite

JSY is a 12-year-old government programme focused specially on 10 states with low rates of institutional delivery–Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Odisha, and Jammu and Kashmir–termed as low-performing states (LPS).

The other 19 states are clubbed together as high-performing states (HPS).

Source: National Family Health Survey 2005-06 and 2015-16

Under the programme, pregnant women in rural areas who live below the poverty line are to be given cash assistance–Rs 700 in HPS and Rs 1,400 in LPS–irrespective of the mother’s age and number of children, so that they opt for birth in a government or accredited private health facility.

In addition, it provides performance-based incentives to women health workers, ASHAs or Accredited Social Health Activists, to promote institutional deliveries.
In reality, the JSY has failed to cover the poorest women, according to this 2014 analysis of JSY data by researchers from Georgetown University. Some focus states report MMRs that match those of world’s poorest countries–Mauritania (320), Equatorial Guinea (290), Guyana (250), Djibouti (230) and Laos (220), IndiaSpend reported in September 2015.

Source: Ministry of Health & Family Welfare

There is a lack of association between MMR and the rise in institutional births, according to this 2013 report, which analysed different government data for 284 districts across nine focus states. It is likely that women most vulnerable to maternal death are not getting the JSY benefits, the report said.

Marandi’s story is repeated in hospitals across India, like this one in Bankeda village in western Odisha’s Subarnapur district. Families of patients are forced to hire private vehicles, pay for check-up and delivery at government health facilities. They do not receive cash incentives–Rs 1,400 under JSY and Rs 5,000 under the state’s Mamata Yojana. “Why should we go to state-run health facilities?” the women ask.

As in Marandi’s case, 60% of women in Uttar Pradesh said they had to pay for certain public maternal health services, according to an assessment of JSY conducted by United Nations Population Fund in Bihar, MP, Odisha, Rajasthan and UP in 2012, IndiaSpend reported in September 2015.

Prime Minister Narendra Modi announced that Rs 6,000 would be transferred directly to the bank accounts of pregnant women who undergo institutional delivery/and vaccinate their children. But as FactChecker found, the option of giving Rs 6,000 to pregnant women already existed in the National Food Security Act (NFSA), 2013–it just had not been implemented by the government.

Not enough doctors, not even toilets at health facilities

There is a 77% shortage of obstetricians and gynaecologists in Community Health Centres (CHCs) nationwide, according to the Rural Health Statistics 2016 released by the ministry of health and family welfare. And 15 states and union territories have more than 90% shortage of obstetricians, gynaecologists in CHCs.

The CHCs constitute the secondary level of health care. These provide specialist care to patients referred from Primary Health Centres (PHCs), four of which feed into each CHC, serving roughly 80,000 people in tribal, hill or desert areas and 120,000 on the plains.

Nearly 62% of government hospitals–which include CHCs, district hospitals and sub-district hospitals–don’t have a gynaecologist on staff and an estimated 22% of sub-centres are short of auxiliary nurse midwives (ANMs), IndiaSpend reported in September 2016. Additionally, in 30% of India’s districts, sub-centres with ANMs serve double the patients they are meant to.

Sanitation facilities at public health centres where women deliver are inadequate as well. In the video, Marandi can be seen struggling to find a toilet after she is given laxatives before childbirth. In one instance, she simply squats outdoors in public to ease herself.

This is not unique to Godda. There are no toilets in half the postnatal wards of PHCs, as is the case with 60% of larger CHCs in MP, according to a study by WaterAid India in 343 healthcare institutions across six states and reported by IndiaSpend in July 2016. Open defecation was allowed within 38% and open urination in 60% of health facilities in Odisha’s Ganjam district, according to the report.

This should not come as a surprise: Of the 4,000-odd multi-crore infrastructure projects in the country, only nine (0.21%), with a total investment of Rs 938 crore, are in the health sector, IndiaSpend reported in December 2015.

There is no guarantee of quality care

“The government encouragement of institutional deliveries is based on the idea that poor people choose to deliver at home either out of ignorance or an inability to make the right decisions or due to cultural norms and the exercise of (male) power,” argued Jishnu Das, lead economist, World Bank in a 2014 blog. “But an alternate starting point is that people were not using institutions to begin with precisely because quality was low, and that increasing quality would also bring more people in.”

The quality of antenatal care is vital to reduce the risk of stillbirths and pregnancy complications, and the absence of it explains why more women enrolling for hospital deliveries does not translate to fewer maternal deaths.

In Odisha, only 23% of women reported receiving full antenatal care, the highest among focus states, according to National Family Health Survey data for 2015-16 (NFHS-4). The figure in Tamil Nadu, which is considered one of the best states to be a mother, was 45%. Only 3.3% of women in Bihar reported receiving full antenatal care, a decline from 4.2% in 2005-06.

Full antenatal care equates to at least four antenatal visits by health workers, at least one tetanus toxoid injection and iron folic acid tablets or syrup taken for 100 or more days.
Source: National Family Health Survey 2005-06 and 2015-16.

Most obstetric complications could be prevented or managed if women had access to a skilled birth attendant–doctor, nurse, midwife–during childbirth, according to the World Health Organization.

The probability of maternal death among Indian women decreased with increasing skilled attendant coverage, among both women who were and were not admitted to a health-facility, according to this 2014 analysis of different government data.

(This story is the result of a collaboration between Video Volunteers, a global initiative that provides disadvantaged communities with story and data-gathering skills, and IndiaSpend. Saha is an MA Gender & Development student at Institute of Development Studies, University of Sussex.)

You can see the full playlist of Video Volunteers’ videos–revealing gaps in maternal-health services–here.

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