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HEALTH-INDIA: Trained Birth Attendants Save Rural Mothers’ Lives

Manipadma Jena

BHUBANESWAR, India, Apr 7 2010 (IPS) - It was her fourth unplanned pregnancy, but Sani Jani still made it a point to have a monthly checkup at the nearest primary health centre – even if she always had to walk two kilometres to get there.

Eighth months into her pregnancy, however, Jani went into labour. Trained birth attendant (TBA) Kamala Bhatra rushed to the health centre to ask for help, and a mobile health van was summoned 25 km away. But it had been sent elsewhere earlier, and never made it to Jani, who eventually died of obstructed labour. She was just 30 years old.

Jani’s story, though, is not that uncommon in India. According to Britain’s Department for International Development (DFID), which partly funds India’s health service reforms, one woman dies every seven minutes in childbirth in this country.

One in every 70 Indian women is expected to die because of pregnancy, childbirth or unsafe abortion, compared to one out of every 7,300 in the developed world, according to 2009 research by Human Rights Watch. The statistics become more dismal in the Indian states of Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, and Orissa – where Jani lived. Out of 100,000 live births there every year, mothers numbering anywhere between 303 to 440 die. These five states alone are responsible for 65 percent of maternal deaths in India.

But at a conference of the non-government National Alliance of Women (NAWO) here recently, hundreds of grassroots health providers, professionals, TBAs and activists said these figures can be improved if the government reconsidered its policy to ignore TBAs like Kamala Bhatra.

Although trained under a government Reproductive and Child Health (RCH) programme, India’s TBAs have been left out by the state National Rural Health Mission (NRHM) that is tasked to provide quality healthcare to the rural poor. Begun in 2005, the NRHM uses “skilled” health assistants, which refer to accredited health professionals such as a midwives, doctors, or nurses.

“In inaccessible hilly forest areas, a TBA is a matronly local, of the same caste and available 24/7,” said Saraswati Swain, a retired gynaecologist with decades of community experience. “Also, most of them had been informally trained earlier.”

Between 1997 and 2005, TBAs were taught about cleanliness and given birthing kits to help deliver babies at the mothers’ homes. In inaccessible, underserved areas they continue to be indispensible during childbirth. Otherwise, at the behest of pregnant women, they only accompany them to and from clinics and do the after-delivery cleanups there.

The NRHM does have trained female community health workers known as ASHAs or Accredited Social Health Activists. Recruited from the villages they serve, ASHAs are the first ports of call for child and mother health issues. Expected to motivate women for clinic delivery, they have no midwife role.

By promoting the ASHA concept, NRHM works on the premise that there should be no domiciliary childbirths.

But participants at the NAWO conference argued that domiciliary births cannot just be done away with a stroke of policy, given rural India’s socio- economic inequity, low literacy rates, traditional customs and practices related to pregnancy and childbirth, and large number of inaccessible habitations.

They added apart from having to consider ground realities, the health system is not yet equipped to handle a large number of institutional deliveries.

As it is, there are severe and chronic shortfalls in the health system’s physical infrastructure, as well as in staff, including the ASHAs themselves.

Activist Sanjukta Satpathy observed that ASHAs have to look after villages that inevitably include lower-caste groups or dalits, still considered untouchables in rural areas. Satpathy said that here, ASHAs may hire dalit TBAs to do their work for 200 rupees (4 dollars).

Moreover, auxiliary nurse-midwives stationed at primary health centres often live not at their rural workplace but in nearby towns. As a result, women have to wait for hours for a public clinic to open.

In Orissa, there is not one gynaecologist at any of the 292 community health centres, and just a few anaesthetists. Uttar Pradesh, meanwhile, has been suffering from a 20 percent shortfall of sub-centres, or health centres closest to the community.

Sushanta Garada of the NGO Nawrangpur Democratic Action – a member of the community-based monitoring body under NRHM – also took note of the Janani (Hindi for mother) Express, a free ambulance service taking pregnant rural women to health centres with skilled birth attendants.

He said that the service costs 250 rupees or five dollars for a distance of 10 kilometres, an amount few can afford. Besides, the Express’s small van- ambulances serve well only if roads exist. In interior areas, women in critical condition have no choice but to be carried on rope cots to get to the nearest clinic.

P K Senapati, a government maternal health programme manager, says that under NRHM, initiatives are being taken to strengthen clinic delivery in Orissa. These include the completion of training of 3,500 skilled birth attendants, which are different from TBAs, as well as adding maternity homes near hospitals for mothers to stay the 48 critical hours post-delivery.

But Orissa health official Annu Garg also conceded: “We realise the continued need for TBAs in inaccessible habitations of 10 focal tribal- dominated districts. We now plan to train them on skills and cleanliness.”