Safe motherhood and institutional deliveries have been talked about in great detail. They’re an integral part of public health in India. The case study focuses on the state of healthcare for mothers in Tamil Nadu.
This study is derived from my time in Bangalore in 2007, working for Mobility India, an NGO helping persons with disability. Based on my learnings and interviews with several people, I submitted a dossier to the Society for Community Health Awareness Research and Action (SOCHARA) in 2010.
Where the Insights came from
I got in-depth insights on safe motherhood from my internship with Mobility India.
Tribal Health Initiative (THI)
In 2009, I had a chance to visit THI, an NGO in Sittilingi, near Dharmapuri in Tamil Nadu. The tribal inhabitants of the village – women as old as 17 – were tasked with managing deliveries and assisting in surgeries by NGO members and senior hospital staff who were also tribals.
The hospital had traditional equipment, built around a homely ambience and resembling tribal houses in the village. The founders designed the hospital’s architecture this way so mothers didn’t feel overwhelmed by grim surroundings. The staff here was also friendly but efficient. Some beneficiaries mentioned that it wasn’t just safe to deliver a baby but it was also an enriching experience. During this time, I was allowed to witness childbirth which was a life-altering experience.
The Society for Community Health Awareness, Research, and Action (SOCHARA)
In 2010, I interned with SOCHARA as part of a Community Health Learning Programme (CHLP). Two health activists at Community Health Cell (CHC) in Chennai guided me through the project. My quest to find more insights into institutional deliveries in Tamil Nadu led to unique interactions with a few experts.
- Dr Sattva, a paediatrician at Chengalpattu Government Hospital
- Dr Raj, Deputy Director of Health Services, Kanchipuram district
- Mrs Rutuja, Maternal and Child Health Officer, Kanchipuram district
- Mr Aarif, health activist at CHC
- Dr Subhida, health activist heading the Rural Women’s Social Education Centre (RUWSEC). Dr Subhida had a particularly interesting goal: to define safe motherhood (in technical and social terms) and create indicators.
- Dr Rawal, CHC – SOCHARA
*Names have been changed to protect the identity
The Rural Women’s Social Education Centre (RUWSEC)
RUWSEC welcomed me for a community-focused group meeting in 2010. They had an interesting goal—to define safe motherhood (in technical and social terms) and create indicators for it. The participants discussed safe motherhood and the requirements to achieve that at home. They also evaluated the quality of services offered by public health institutions.
Maternal Mortality Rate (MMR)
MMR is the basis of this research and case study.
As the name suggests, the maternal mortality rate shows the number of females who die from pregnancy-related causes or are made worse by it. Ill-managed practices during pregnancy can also lead to maternal mortality. WHO provides a much more detailed explanation, but for this study, let’s note the points mentioned above.
Based on Dr Subhida’s insights, infant mortality was a massive issue until the 1980s. Then, a document named ‘Where is the M in MCH?’ (Rosenfield, A.; Maine, D.) published in 1985 changed things. The article questioned the minor importance given of mothers in Maternal and Child Health (MCH) programmes. The document became widespread and maternal mortality became an urgent issue worldwide.
India adopted several schemes, too. For example, the Janani Suraksha Yojana (JSY) scheme provided extensive emergency services and pushed deliveries to primary healthcare. As a result, a slow rise in institutional deliveries from 25% to 80% was observed. But the scheme was a failure. Even though the supply of these services was less than the demand in other places, Tamil Nadu had a higher supply and lower demand. Thus, the JSY turned out to be successful in the state from the 1980s.
At one point, the Indian government also used Traditional Birth Attendants (TBAs) to assist with pregnancies.
According to Dr Subhida, TBAs conducted home deliveries in villages. With the intervention of the Indian government, they were then trained as midwives to reduce maternal mortality. However, this project was abandoned entirely and deemed a failure. The government did not evaluate the training modules. It did not take steps to check flaws and errors. On the other hand, it blamed the midwives for the project’s failure and their lack of knowledge.
As per Mrs Rutuja, midwives no longer conducted or assisted in deliveries as of 2010. They’d been debased and removed from their jobs. Nor were they recognised as authorised experts for deliveries. A few ended up acquiring jobs as sanitary workers in Public Health Centres (PHCs). They did menial work, earning a salary of INR 500 per month.
Government’s stance on Home Births
To government and public health officials, home births were unhygienic and brutal. However, villages could achieve safe motherhood at PHCs having technological provisions.
People delivering children at home didn’t know how to handle them. There was no electricity or space for equipment. Especially in poor homes, mothers had to lay down on the floor when giving birth. Also, some mothers worked right until the day of delivery. If there was an emergency or premature labour, getting these mothers to PHCs was difficult as the mothers lived in remote villages.
On the other hand, if a mother decided to give birth at a PHC, she could arrive there a day prior and stay for three days after delivery. She’d receive proper monitoring, and specialists could attend to her complications. In addition, the PHC could audit and account for emergencies and deaths. These services were available at PHCs, and couldn’t be possible on a door-to-door basis (sending healthcare staff to remote villages having pregnant women).
As per insights gathered from Dr Raj, mothers in villages gave their babies sugar water which can be fatal. Dr Sattva also pointed out that some TBAs cause infant deaths. These TBAs gave oil baths to the babies, blowing into their mouths and noses to remove dirt. As a result, babies catch pneumonia and infections.
To uphold safe motherhood, mothers have to take care of birth spacing, nutrition, ante-natal check-ups and iron/folic acid abundance. According to Dr Sattva, mothers also needed guidance about negligence at home, breastfeeding, hygiene, medication, consanguineous marriage and nutrition. But they were ignorant or illiterate and didn’t know about these things. As a result, they didn’t go to specialists when they were referred to mitigate complications. Instead, they worried about expenses and relied on faith-based treatments.
Government Programmes to address MMR
One of the reasons the National Rural Health Mission (NRHM) came into being was to reduce MMR.
Dr Raj explained the public infrastructure before and after NRHM, which looked like this :
- Upgraded 30-bed PHCs: Deliveries happened 24*7. X-ray and Operation theatre were also available.
- Block PHC: Operation theatre, 2 staff nurses were available round the clock.
- PHC: Catered to a population of 30,000. Auxiliary Nursing Midwives (ANMs) conducted a few deliveries.
- VHSCs: 5 or 6 were available. ANMs did all deliveries.
At VHSCs, there was an acute shortage of equipment and a lack of quality services. Therefore, child deliveries mostly happened at block PHCs. Before NRHM, accessing public healthcare was a significant challenge for mothers. But the NRHM introduced 12 services to mitigate this problem. These were
- PHCs working round the clock
- Establishment of basic emergency obstetric services
- Reproductive Tract Infection (RTI) and Sexually Transmitted Infection (STI) clinics
- Mobile medical units
- Indigenous Indian System of Medicines (ISM) drugs
- Hiring of specialists
- A good amount of funds for caesarean operations
- Family planning services
- Patient welfare societies
- Village health and sanitation committees
- Scan centres and audits
- ‘108’ ambulance services
Dr Raj has been involved in several health service innovations himself when he was posted at Vellore and Kanchipuram as a deputy director for public health. The government used these as inspiration and directed PHCs in other districts to follow the same. A team of directors regularly visits him to observe these innovations to incorporate it across various places.
Government Policies to reduce MMR
The Kalaigner’s Insurance Scheme was introduced to benefit families with an annual income of less than INR 72,000. Dr Raj offered more insights into this. It wasn’t a scheme exclusively for reducing MMR but a health scheme that could work in that direction. For instance, there were 22 welfare boards—the welfare board of construction workers. People under Kalaigner’s insurance were given smart cards for private and government hospitals. Families could avail nearly 52 types of treatments in this scheme.
The JSY scheme targeted families below the poverty line (BPL) to reduce the MMR across India. It provided mothers with INR 1,400 for their nutrition, antenatal care, and perinatal and postpartum care. JSY was a better, improvised version of the Muthulakshmi Reddy Scheme (MRS), specific to Tamil Nadu and provided INR 6,000 instead.
Some flaws of JSY, as pointed out by healthcare professionals, activists and government officials, were that the scheme was not for mothers:
- below 19 years of age.
- having more than 2 children
- living at their husband’s house during pregnancy
The MRS had its share of shortcomings, too:
- Dr Subhida mentioned that various governments manipulated the scheme for several periods. The amount was gradually increased from INR 45 to INR 6,000 to gain political favour and votes from mothers.
- The amount had no actual benefits as the families paid it for getting ambulances and other bribes.
- Mr Aarif observed that mothers didn’t receive the money in instalments before delivery. Instead, they got it only once they registered with the government. So, in reality, mothers did not use the funds on nutritional care during the antenatal period, which defied the scheme’s purpose.
- He also suggested that the government integrate the nutrition scheme with the Midday Meals Scheme (MMS) by giving meals to mothers every day instead of providing the money. But the government was reluctant to adopt this method.
- Mrs Rutuja mentioned that people not really in the BPL category also benefit from MRS. This money is never used for healthcare. Nonetheless, some people who are genuinely in need do receive the money, too. Hence, the scheme may be an eyewash but can’t be completely terminated.
- She thinks that integrating mothers into MMS needs a lot of time, effort, and money, which the government can’t provide. So, reaching the quantity limit may be possible, but quality? Not so much.
- Mothers come for screening during the 7th, 8th and 9th months. In a day, at least 120 mothers turn up. Sometimes, mothers who are due even during the 6th month turn up. Organising food for so many people is an uphill task for the PHC staff. However, if the government considers the proposal and allocates a separate department to execute the project, it could be possible to include mothers in MMS.
Reality: Safe Motherhood is not so safe
According to Dr Subhida, the Tamil Nadu government was successful enough in reducing MMR, but maternal morbidity remained an unaddressed problem in both the short and long term.
Dr Raj’s take on this issue is screening and treating for maternal morbidity during the 7th, 8th and 9th months for mothers who may face complications. These complications could be heart diseases, hypertension, eclampsia, gestational diabetes, infant morbidity, and anaemia among others.
But Dr Subhida mentioned that maternal and infant morbidity during delivery still prevailed. Post-discharge, mothers are not followed up. She hadn’t seen public health institutions keeping track of postpartum complications, statistics, and quality of care received.
A few health workers spoke about system gaps in auditing deaths and morbidity incidents. For example, maternal or infant morbidity during delivery or within the postpartum period had to undergo government auditing. Then, health workers had to take the families to the collector to make the report. During this procedure, the government staff is negligent and provides low-quality services. They don’t know how to tackle complications. Plus, they disrespect health workers in villages, wrongly pointing out that they’re not knowledgeable. They also get evasive and blame the health workers if there’s an issue or system failure to save themselves from higher authorities.
Cultural, Gender and Social Discrimination
Abortion, contraception and family planning became cultural and religious issues. Dr Subhida reported that mothers faced discrimination and had privacy and abortion issues. The abortion process itself was tedious and dangerous. Contraceptives for women weren’t widely available, and if they were, they were expensive for the poor.
Married mothers were less discriminated against as the government wanted to promote family planning. But unmarried mothers faced the worst. Indian society treats premarital sex and motherhood as blasphemy.
Dr Subhida also mentioned that the government is selective about the message it wants to spread. For example, women-controlled options aren’t considered, especially in the case of safe abortions. On the other hand, condoms (a male-controlled option) are spoken about to prevent pregnancy. Emergency contraceptive pills are not made available. And family planning is a painful, manual procedure for mothers.
There were social issues when it came to the accessibility of services. For instance, people having HIV or coming from Scheduled Castes (SCs) and Scheduled Tribes (STs) were discriminated against—even if they had the money or cash incentives.
When gender bias was discussed with Dr Raj, he said that public health officials tried to popularise male sterilisation and nose scalpel vasectomy, a Chinese procedure. The programme was ongoing at the time, running on government funds. Moreover, the staff tried to negotiate with the government about increasing Oral Contraceptive Pills (OCPs). Dr Raj also countered that in Vellore, 70% of PHC users belong to SCs and STs, even the most backward caste —Vannier. Therefore, there isn’t any special or inferior treatment for anyone; it’s all equal.
The information gathered from Dr Sattva showed that most complaints were about patients and caretakers sleeping on the floor as there were insufficient beds. Also, a single hygiene worker was appointed for a whole government hospital building in Chengalpattu.
Some beneficiaries and health workers also complained about the toilet facilities. As a result, a few NGOs charged patients and workers for using the toilet. Other times, most of the health facilities were unsafe or delivered late. They couldn’t keep up with the number of patients. Plus, the quality of deliveries and vaccines for children was low.
The ideal staff to patient ratio in a government hospital, as suggested by Dr Sattva, was:
- 1 nurse = 1 baby with severe complication
- 1 nurse = 8 babies who need medication
- 6-7 paediatricians = 40 babies
- 1 social worker
In reality, there was only one sanitary worker for the entire building that had different departments. 1 paediatrician catered to 50 babies and there were only 3 nurses in all. A social worker was absent. Staff in secondary and tertiary hospitals were even lesser—no number of petitions and complaints brought about radical action from the government. Also, the government was building new hospitals across Tamil Nadu. It abandoned them completely since it didn’t profit enough from old hospitals.
Nonetheless, the government made some efforts. It moved the workload to PHCs at the tertiary level where the doctors could take care of complications. Plus, the government was certifying MBBS holders for diabetology and anaesthesia by training them in PHCs.
Mrs Rutuja observed that when sometimes a PHC gave referrals, the staff of government hospitals didn’t receive them immediately.
For Dr Raj, working with government directors was challenging since only a few were sincere and motivated. There were also chances of clashes between directors of different districts. There was pressure applied from his higher authorities, too. Sometimes, the government was benevolent enough. But other times, it discarded several suggestions owing to monetary inadequacy, system gaps and staff shortage.
The Move of Immunisation Services
Voluntary health nurses (VHNs) were supposed to visit households to advocate healthcare, conduct antenatal checkups, and provide polio vaccination. But the immunisation services were moved to PHCs, meaning mothers had to travel to the PHC for one injection, which was very hard.
Dr Raj spoke about an incident that pushed the government to move services to PHCs. In 2008, some VHNs in the Thiruvallur district of Tamil Nadu gave immunisations to babies without testing them for issues like chest congestion or pneumonia. This issue proved fatal, resulting in the death of four infants. Therefore, immunisation shifted to PHCs where a Medical Officer (MO) could conduct checkups and tests before administering vaccines. Through NRHM, MOs can also conduct inspections using Mobile Medical Units (MMUs) at different places.
People weren’t happy with the move, leading to protests and complaints. But the government didn’t want to be responsible for more child deaths.
Inefficiency of ANMs
I had the opportunity of accompanying Mrs Rutuja for an inspection at two upgraded Block PHCs – in Parandhur and Thiruppukuzhi (Kanchipuram district). The government recently upgraded Block PHCs to 30-bed ones. At Parandhur, the government organised a food Mela for pregnant women. The women were given nutritious food and also screened for complications. It was an innovative pilot project executed by Dr Raj in all PHCs of the Kanchipuram district.
The two upgraded PHCs had labour rooms. And mothers of different types of labour, as well as women who’d undergone abortions, were also placed there. I found that the delivery room isn’t a separate room on checking it out. It’s slight seclusion in the same room as the labour ward. Another delivery cabin next to the current one wasn’t used and was badly maintained. It wasn’t used unless there were two simultaneous deliveries. The staff weren’t in their uniforms either.
At another time, I witnessed Dr Raj conduct an inquiry into an incident involving an ANM in Vallam PHC. The ANM had read the partograph of two labour cases the day before. Both mothers were facing complications since their labour hadn’t progressed for 6 to 8 hours. Even though she knew that it was an emergency and the mothers must be transferred to a government hospital, she retained them at the PHC for over 11 hours. As a result, she was sacked.
According to Mrs Rutuja, ANMs worked on deliveries single-handedly, leading and taking responsibility. This practice was unlike private hospitals, with several professionals to assist. ANMs were expected to know the signs of complications and when to refer the patient without any delay. They were also supposed to screen mothers in the 7th, 8th and 9th months. By then, they should have anticipated if a case would be natural birth or caesarean.
Some ANMs were very new to the job, which made them practically inefficient in handling deliveries by themselves. They may have had sound knowledge in theory but lacked in practical applications. ANMs were given training before being posted at PHCs. However, all they needed was a certificate authorising them as health workers. In addition to the above, they were paid only INR 7,500 per month while being overburdened with responsibilities.
Lack of Follow ups
Generally, mothers stay in the hospital for 3 days during delivery, after which, they are discharged. They’re supposed to come back for regular follow ups. However, some doctors were absent for antenatal check-ups.
Mondays and Wednesdays were reserved for outpatient consultations. But doctors were never available on Wednesdays. So even for emergencies at 11 in the morning, the clinics were closed. Only bed patients were treated. Pregnant women or postpartum mothers were forced to purchase beds in the hospital to get a check-up done.
Bribes and Violation of Patient Rights
Some health workers pointed out that the hospital forced mothers to purchase covers, soaps, and blades, which it should otherwise provide for free. The staff took care of the patient depending on the bribe given.
Government hospital doctors also took bribes at clinics during private practice, especially during antenatal check-ups. The bribes taken in government hospitals were also on the rise.
Based on Dr Sattva’s revelations, people paid INR 1,000-1,500 for an ambulance for babies. With new government rules, they could get it for free. However, the ambulances were ill-equipped, and there was no emergency equipment. For instance, something as crucial as oxygen tubes was absent. So, by the time a baby arrived at the hospital, chances are it was dead. Emergency transport was supposed to be freely available on paper, but in reality, people still paid bribes for it.
One of the most prominent complaints from health workers was physical abuse and coercion at public health institutions. Fundamental human rights and dignity were being tampered with—for mothers and VHNs alike. VHNs felt pressured by higher authorities, while mothers didn’t even get to choose a hospital of their liking.
Dr Subhida and her federation, RUWSEC, once organised a talk about the Birth Companionship Programme (BCP). It received an overwhelming response coupled with outrage towards the government for not informing them about such a thing before. It was an essential scheme as they’d previously faced a lot of abuse when it came to caretaking. A copy of the government order (GO) was then given to all women. But several of them were still denied access to mothers at government hospitals and the GOs were rejected.
What are the possible Ways Forward?
During my internships and subsequent research, I had several focused group discussions with beneficiaries, health activists, and healthcare service providers of districts around Chennai, as organised by RUWSEC.
These discussions brought various gaps in Tamil Nadu’s public healthcare system. Here are a few suggestions made based on these findings and understanding.
- Abuse of women must be permanently ceased.
- Bribe and corruption should be abolished.
- All services that are free on paper must be free in reality.
- Unsafe abortion should be checked.
- Basic medical provisions ought to be made: for example, generators, well-equipped ambulances, blood banks, disposable needles, pregnancy/delivery tables, incubators, operation theatres, and clean toilets, among others.
- Qualified, professional medical officers must be accessible at all times. These are nurses, midwives, gynaecologists, surgeons, child specialists, paediatricians, consultants, counsellors (for pre-and post-delivery).
- Timely follow-ups must be made for the postpartum period.
- Family or social support systems need to be well rounded. The families must be sensitised about nutrition, hygiene, assistance in medical procedures, and the birthing process.
- A caretaker must be allowed to be with the mother during delivery.
- Mothers should have the right to choose the hospital or clinic and doctors.
- Technical aspects of medical policies must be discussed with beneficiaries.
- Complications that can be treated must be handled efficiently.
There were also several events discussed. For instance, deliveries can also happen at home. Syringes can be bought from nearby shops to control haemorrhages as this can help women attend to emergencies at home instead of travelling long distances to PHCs. Midwives can be trained to administer injections and better use medicines and equipment. With all of this, safe motherhood can be practised at home, too.
Summing it up
While the above is possible and safe motherhood can happen anywhere – in the hospital or at home – the reality is different. Equipment available for home deliveries may not be of great quality. Nonetheless, mothers should have the right to choose where they want the delivery to happen. Safe motherhood at home is an ideal for now, but can be made practical gradually.
While the above is possible and safe motherhood is possible anywhere—in the hospital or at home—the reality is different. Equipment available for home deliveries may not be of excellent quality. Nonetheless, mothers should have the right to choose where they want the delivery to happen. Safe motherhood at home is ideal but can become practical gradually.
This study provides a comprehensive view of safe motherhood and public healthcare facilities in Tamil Nadu. It also evaluates the quality of services, the on-ground situations and how the state can execute better. In addition to all this, it allows us to envision the scope for making safe home delivery a reality by adding a few complimentary services instead of institutionalising them.
- ANM – Auxiliary Nursing Midwife
- BCP – Birth Companionship Programme
- BPL – Below Poverty Line
- CHC – Community Health Cell
- CHLP – Community Health Learning Programme
- GO – Government Order
- ISM – Indian System of Medicines
- JSY – Janani Suraksha Yojana
- MCH – Maternal and Child Health
- MO – Medical Officer
- MMR – Maternal Mortality Rate
- MMU – Mobile Medical Unit
- MRS – Muthulakshmi Reddy Scheme
- NRHM – National Rural Health Mission
- OCP – Oral Contraceptive Pill
- PHC – Public Health Centre
- RTI – Reproductive Tract Infection
- RUWSEC – Rural Women’s Social Education Centre
- SC – Scheduled Caste
- SOCHARA – Society for Community Health Awareness Research and Action
- ST – Scheduled Tribe
- STI – Sexually Transmitted Infection
- TBA – Traditional Birth Attendant
- THI – Tribal Health Initiative
- VHN – Voluntary Health Nurse
- VHSC – Village Health Subcentre