Surviving child birth is a fundamental right of every woman. Yet more than 100,000 die every year due to pregnancy and child birth related causes. Clearly, most of these lives can be saved!
The UN Summit on the Millennium Development Goals (MDGs) in New York has focussed on this issue. Many new commitments were made for women’s and children’s health. More than $40 billion was pledged, over the next five years to save the lives of over 16 million women and children, preventing 33 million unwanted pregnancies and ensuring access for women and children to quality facilities and skilled health workers.
India has to play a pivotal role if MDG 5 for reduction of maternal mortality ratio (MMR) by three quarters is to be achieved. Put simply, it implies a reduction of MMR from 301 to 75 per 100,000 live births. This is difficult. Out-of-the-box solutions will have to be found and synergistic partnerships developed with the private sector to prevent these deaths.
India accounts for the largest number of births (27 million) worldwide, every year. A large majority of these are in the rural areas and take place at home without the presence of skilled birth attendants. There are trained nurse/midwife in 30 per cent of the villages, but they are not skilled to handle even ordinary deliveries, not to speak of complicated cases.
The lack of availability and access to essential health services results in the death of 1,17,100 mothers and more than a million infants within critical 28 days of birth. Ironically, trained obstetricians are available mostly in the private sector. For reasons such as lack of amenities, poor salaries and government policies, only a few work in the government in the rural areas. For example, of the 2000 obstetricians in Gujarat, only seven were practicing in the block level hospitals which serve the poorest population.
A similar situation exists in UP, Bihar, Rajasthan, Chhattisgarh and Jharkhand. Consequently, the MMR in the rural areas worsened during the Nineties from 448 to 619 per 100,000 live births. Those lucky to survive, may, in many cases, suffer from incontinence, chronic pelvic pain, dismennorrehea and other complications of a badly handled delivery.
The Gujarat government’s innovative Chiranjeevi scheme has ensured safe deliveries for Below Poverty Line (BPL) population. Under it, for long life of mothers and children, the private obstetricians were contracted to provide skilled birth attendance and emergency obstetric care free of charge to poor rural women. In return, the government paid the obstetricians Rs 1,79,500 for a package of 100 deliveries including treatment of complications. The average price per delivery came to Rs.1795.
The criterion for selection of private obstetricians was kept simple to get good representation. The scheme was developed in consultation with IIM, Ahmedabad; Sewa Rural, Jhagaria and the Federation of Gynaecological Societies of India (FOGSI). The doctors are paid, in consultation with FOGSI, on the basis of the actual cost in a rural setting for Sewa Rural, a reputed non-government hospital in a tribal area of the state.
The Chiranjeevi scheme was started as a pilot in 2005-06 in Gujarat’s five districts. The response was phenomenal: 75 per cent of the private obstetricians in those districts joined the scheme willingly. From January, 2006 to March 2008, around 97,000 poor women delivered in private hospitals under the scheme. Each obstetrician did an average of 500 deliveries and earned up to Rs 9 lakh from the scheme. The scheme turned out to be a win-win situation for poor women, private doctors and District Health Authorities.
The government bagged the Asian Innovation Award for its initial efforts. Soon the scheme was extended to the whole state. Over 800 private obstetricians are currently working with the government; they have carried out 5.35 lakh BPL deliveries in the last four years. The coverage of deliveries under the scheme averaged 53 per cent of the total BPL deliveries.
The beneficiaries include 38,812 women who underwent caesarian deliveries and 26,730 women who had complicated deliveries free of cost. This prevented destitution and misery as many rural families go bankrupt for undergoing complicated deliveries. The scheme saved many lives. In the normal course, 1611 women may have lost their lives during these deliveries. However, due to skilled birth attendance, only 87 maternal deaths were reported under the scheme. Similarly, a large number of early neo-natal deaths were prevented because of skilled care during birth. The total cost to the state for the 5.35 lakh deliveries has been Rs 960 million or Rs 240 million annually.
The Chiranjeevi Yojna is only one of the components of the strategy for improving maternal health. Simultaneously, steps were taken to upgrade peripheral health infrastructure, effectively implement the Janani Surakasha Yojna, train MBBS doctors in emergency obstetric care and auxiliary-nurse-cum-midwives as skilled birth attendants.
Consequently, the institutional delivery rate, the best proxy indicator for a safe delivery, which was increasing at the rate of 1 to 2 per cent every year, increased from 55 per cent in 2005 to 90% in 2009. In all, 108 Emergency Trauma Care Service vehicles ferried the poor expectant mothers to safe delivery centres in the public or private sector.
There is significant improvement in institutional deliveries among the BPL population with high level of client satisfaction. An evaluation by Indian Institute of Ahmedabad shows that most Chiranjeevi users have an income of less than Rs 12,000 per annum, indicating that the scheme is able to target the poor families. The users are relatively younger mothers and having lesser number of children. ANMs, Anganwadi workers and female health workers provided information to 82 per cent Chiranjeevi clients.
The Chiranjeevi Yojna has obvious lessons for other states. Despite the tremendous success of Janani Surakasha Yojana (JSY), of the 55 lakh births in Uttar Pradesh annually, only 21 lakh take place in institutions today. Thirty four lakh births still take place in unsafe surroundings making the expectant mother and the neonate very vulnerable. It will be very difficult for the government to provide safe delivery facilities to the remaining 34 lakh expectant mothers as most hospitals are fully utilised.
There are 4,000 private obstetricians in UP. They could be involved to provide safe delivery facilities to the poor women. In states like Jharkhand, only 20 per cent have access to safe delivery facilities. In Delhi, 32 per cent women in the slums and other poor areas deliver in unsafe surroundings. There is need to involve the private sector in enhancing safe delivery facilities for the poor.
Fears that the private sector’s involvement would eat into the government’s work are unfounded. In the above illustration of UP, there is enough work for public and private sectors. Even the Gujarat experience shows that after four years of an active partnership with the private sector, the public sector deliveries have increased both in percentage and absolute terms.
The Chiranjeevi experience has been profiled in the UNICEF’s State of the World’s Children Report 2009, as a unique initiative to improve maternal and child health. The South East Asia Region of World Health Organisation invited 11 countries in the region for a workshop in Ahmedabad to visit the private partners and learn about the scheme.
The Chiranjeevi scheme provides the first practical experience of involving private obstetricians on a large scale to deliver skilled birth attendance and emergency obstetric care to poor women in Gujarat. It demonstrates the possibility to contract private sector to increase rapidly, availability and utilisation of skilled birth attendants for the poor at a reasonable price. It appears to be a viable strategy for other states of the country to achieve the UN millennium development goals pertaining to mother and child health.
There is also a possibility of extending the scheme to cover screening for cervix cancer, HIV/AIDS and provision of high quality sterilisation services. In Gujarat, 258 private paediatricians are already working with the state government under the Bal Sakha scheme to provide expert care to critically ill neonates.
Such efforts, however, would require a proactive and a dynamic leadership from the top health managers at the state level and committed team work of peripheral health staff including nurses, health facilities, medical officers and private obstetricians. The returns, in terms of maternal and neonatal deaths averted, would be worthwhile.
The writer, a senior IAS officer, is Executive Director, National Population Stabilisation Fund, Government of India, New Delhi
Saving the mother and the child
l Annually, 78,000 women die from pregnancy and childbirth in India, which means one woman dies every seven minutes.
l In India, two-third mothers die within seven days after delivery. If we focus on these first seven days, we can reduce our infant mortality rate and maternal mortality rate.
l If women have access to essential maternity and basic health care services, up to 80 per cent of all maternal deaths and injuries could be avoided.
l Almost one in four women (23 per cent) receive no antenatal care, ranging from 1 per cent or less in Kerala and Tamil Nadu to 66 per cent in Bihar. At least 40 per cent of pregnant women did not get any antenatal care in Jharkhand, Arunachal Pradesh and Nagaland.
l There is need for increased investment in maternal and neonatal care in India which should be given priority in budget allocations.Funds must be used effectively to ensure that life-saving services reach all those who need them.