September 26, 2016

Chronicles of Deaths Foretold: Part 2 - Policy recommendations

Data from the health ministry shows that only 42% of maternal deaths are being reported. Out of them 67% are institutional deliveries. Nearly 20% of women are dying during transit.
Experiences from the field indicate the same.

“We have 120 medical colleges, only 55 are reporting maternal deaths to us. We have sensitized them, but it is not picking up,” saidDr. Veena Dhawan from the Ministry of Health and Family Welfare.
She listed many initiatives of the government to reduce maternal deaths. “But the implementation lies in the hands of the State governments. We can only make policies at the Centre,” she said.  
The report was presented to Dr. Veena Dhawan, assistant commissioner, maternal health, Ministry of Health and Family Welfare and Dr. Prasanth of National Health System Resource Centre.


In the two-day consultation, organized during the release of report “Chronicles of Deaths Foretold,” activists strongly demanded accountability for lapses when a woman dies. They said that there should be enquiry into maternal deaths, responsibility fixed and culprits punished. When there are protocols, then someone should be punished if they are not followed and lead to deaths.

Based on the report and the consultation on maternal health, the civil society organizations came up with recommendations. Five suggestion that NAMHHR believes have to be implemented immediately are:
  1. Ante-natal check-up (ANC) must identify high-risk cases – use RED FLAG to signify a high risk for all providers
  2. EMERGENCY HELP DESK in all facilities used by ‘populations at risk’ with compounded vulnerabilities
  3. Develop Adverse Outcome Management protocols, monitor use in HPDs
  4. Blood storage at all FRUs; in emergency situations, no donor requirement
  5. Free REFERRAL transport to tertiary facilities with paramedic (EMT)- even if across state border; a simple PHONE CALL to next facility  
The 10 medium-term recommendations are
  1. System of using MCTS information to prevent/prepare for any adverse outcomes
  2. Skill training of all nurses and ANMs in safe childbirth, including ANMs in sub-centres/community
  3. Adequate  nurse/ANM posts & appointments according to case-load
  4. Ensuring visits to each CHC by a Gynaecologist at least once every 15 days
  5. Ensuring  essential drugs for maternal survival are available, and using generics
  6. Providing Iron-sucrose injections for very anaemic women at CHC/PHC
  7. Strong feedback loops for JSSK, with User participation
  8. Acknowledgement and Regulation of the private sector  including informal providers
  9. Stronger monitoring of data based on AHS estimates; counting numbers of anaemic women, checking maternal death reports and doing CB-MDR with CSO support
  10. Involvement of PRIs in identification of maternal deaths, process of death review & community awareness
  11. Free hearse service for bereaved families
Dr. Abhijit Das, director, Centre for Health and Social Justice, said that the government should create a feedback mechanism from community experience. We can use ICT for a platform through which every citizen can provide their experience. It will be anonymous but will have important indicators like geographical area and facility where the person was treated. This can further be consolidated and feedback sent to specific facilities for their improvement.

“We do not need new schemes and announcements. We need to ensure implementation of what already exists. We need to hold people accountable when they do not implement policies,” said Renu Khanna from Sahaj, Gujarat.
Jashodhara Dasgupta from Sahayog, nodal organization that prepared the report, said that an overhaul of the current system is the need of the hour. “Our evidence through the report shows that the current way of working has not produced results. The model of JSY+ ASHA+ EmOC/JSSK has not worked, especially in marginalised areas and communities. We have rethink and look beyond the existing system”.

Sterilisation judgment: Beginning of a longer battle to reorient family planning programme

-- By Maya Palit
In April 2012, Salamuni and her husband, a rickshaw puller based in Bundelkhand, visited a hospital in Chitrakoot. She was pregnant and ill, and they assumed she would get better medical treatment there. The doctor on call, Ranjana Sharma, was aggressive in her attempts to convince Salamuni to have a sterilisation operation. Despite Salamuni insisting that she was too weak, Sharma made her sign a document, gave her an injection, and initiated an abortion as well as sterilisation before the anaesthesia kicked in. According to Salamuni’s account, the doctor spent three hours pumping air into her to locate the nerve, and when she screamed from the pain, the sari she was wearing was stuffed in her mouth before she lost consciousness. She had to spend eight days recovering at a hospital in Allahabad after the ordeal because the bleeding wouldn’t stop, she told activists from Sahayog, a women’s reproductive health advocacy group.
Salamuni’s case was an extreme version of the scores of botched sterilisation jobs that are frighteningly common in India. Earlier this year, the central government reported 113 deaths caused by tubectomy surgeries in the last year, but several women’s health activists have rejected this as a conservative estimate, and the National Alliance on Maternal Health and Human Rights (NAMHHR) suggested during a press conference last Friday that approximately 1,000 of the 4 to 5 million women who undergo sterilisation die every year. This has been attributed to the appalling conditions under which the abdominal operation is conducted – often in dharamshalas, under torchlight at night, sometimes with very poor hygiene and unsanitary tools like bicycle pumps and rusty scalpels.
The particularly horrific case of the 18 women who died in 2014 after contracting septicemia and other complications in a sterilisation camp in Bilaspur, Chhattisgarh is now widely known. RK Gupta, the doctor who operated on 83 of those women over five hours was briefly put in police custody but then released because of insufficient evidence. The news that in the same year he had been rewarded for his ‘record’ career of 50,000 surgeries only epitomises the target-obsessed mentality of the Family Planning programme.
It was the gory details of a similar incident that took place four years ago — when 53 Dalit and Scheduled Caste women were operated on at night in a government school in Araria, Bihar — that convinced the Supreme Court last week to direct the Centre to end sterilisation camps across the country, acting on a petition filed in 2012 by health rights activist Devika Biswas. Activists working on maternal health and human rights have since organised meetings to discuss the implications of the judgment. While they welcomed the decision, they were not optimistic about the 3-year transition period which the Court provided the Centre, and said that until an actual blueprint is written out to end these mass camps, it is difficult to say what impact the judgement will have.
Kavita Krishnan, Secretary of the All India Progressive Women’s Association and member of the CPM pointed out at the conference that the family planning debate is still very much centred on tackling population control rather than focusing on women’s reproductive rights: "The question [should not be] about which is the next best technological fix in contraception but about what actions will empower women to gain control over their bodies, and encourage men to take responsibility for contraception," she said. Unfortunately, the focus on population control has governed family planning since the late 80s, ever since the Pomeroy method of tubal ligation through laparoscopy made abdominal operations easier to conduct. And as Deepa Dhanraj’s 1991 film Something Like A War shows, doctors had begun conducting them in unsanitary situations early on: “I spend 45 seconds per operation. I have conducted 3,13,939 operations, this year, more than two thousand in schools and government halls…” says one gynaecologist in the film.
Abhijit Das, co-founder of Healthwatch Forum and a trained doctor working at the Centre for Health and Social Justice in Delhi, added that paranoia about the population explosion has been so deeply ingrained in the public mindset that the government feels justified in its search for quick-fix solutions. The alternative, he says, is aiming for population growth to be spread over years: “India has a very young population. What you want is for reproduction to take place over time, rather than people having many babies and getting sterilised at 24. Sterilisation should also happen later because it has been associated with high regret and hysterectomy rates.”
One of the most crucial questions that was raised at the NAMHHR conference concerned the (lack of) temporary contraceptive and alternatives in the family planning programme. The post-partum intra-uterine contraceptive device (PPIUCD) is another measure that has been gaining popularity. Rajdev Chaturvedi, from the Gramin Punarnirman Sansthan in Azamgarh, Uttar Pradesh, spoke about increasing cases of the device being inserted without women’s consent or knowledge after they give birth. He was also skeptical about the impact of the judgment, claiming that the real change would involve the improvement of access to counselling for women regarding contraception, as at the moment they are targeted while they are vulnerable and in pain during deliveries.
Jashodhara Dasgupta, a coordinator of Sahayog who also works with Healthwatch Forum, UP, emphasised the importance of expanding the objectives of family planning to include a variety of contraceptives so that women can make “informed choices”. These include measures for those who find the PPIUCD invasive or adolescents at the start of their sexual lives, for whom sterilisation is entirely unnecessary. “The government has put off a long-term vision that encompasses the diversity of people’s needs for so long,” she said.
But the reason that non-consensual sterilisation is so rampant in the first place is because doctors are given annual (unofficial) targets or ELAs (Expected Levels of Achievement) to fulfil. Although the recent Supreme Court judgement directs the government against encouraging “incentivised consent” or setting even informal targets for health workers, this may well conflict with India’s commitment to providing contraceptive services to 48 million additional users as part of its family planning goals for 2020. And as of last year, more than 80 percent of the annual family planning budget was spent on promoting sterilisation. Even though the most recent National Family Health Survey statistics suggest that female sterilisation has decreased overall in many states in the last decade, in states like Andhra Pradesh, as many as 68.3 percent of women across rural and urban areas have undergone sterilisation — it doesn’t look like a problem that can be completely eradicated right away.
It remains to be seen, then, whether this judgement will be the beginning of a much longer battle to reorient the family planning programme.
The Ladies Finger (TLF) is a leading online women’s magazine delivering fresh and witty perspectives on politics, culture, health, sex, work and everything in between.

September 23, 2016

Chronicles of Deaths Foretold:Part 1 - Experiences from the field

Sunita Devi (name changed) breathed last in a district hospital in Godda district of Jharkhand while delivering her baby. Devi was 28 year-old and died due to absence of blood in the hospital. She was already delayed in reaching the hospital as her family took time in arranging money for the ambulance.

The family had to mourn two deaths as her child too was still born. The family also had a debt of Rs 15,000 by the end of entire affair.

“Such experiences discourage people from going back to the public health system. If a woman delivers her first child in a health facility, she resists going through the same experience for future deliveries,” said Jiban, an activist from Odisha.

Devi’s story is one of the 20 from Jharkhand that have been documented in the report “Chronicles of Deaths Foretold,” released 19th August, 2016 in Delhi. Like her, most of the women died of heavy bleeding. Either there was no provision of blood in the hospital, or they were asked to pay a hefty sum of Rs 2000-3000 per bottle. By the time families from economically weaker sections arranged for the money, women were dead.

Prepared by the National Alliance for Maternal Health and Human Rights (NAMHHR), the report documents in details the events that led to 139 maternal deaths in seven districts of four states of India – Jharkhand, Odisha, Uttar Pradesh and West Bengal. All these women are from marginalised communities. Study areas like Godda in Jharkhand or Mayurbhanj in Orissa are tribal dominated, Murshidabad and Malda and West Bengal have poor Muslim populations whilst in Azamgarh, Banda and Mirzapur in Uttar Pradesh, most women who died were from either Dalit or OBC or Muslim backgrounds.

The aim of the report was not to look at medical reasons of death – which are usually recorded as heart attacks. The aim was to find causes that led to delays in their treatment that ultimately resulted in their deaths.

The narratives show that women are going to health facilities, but the health facilities are not equipped to handle emergency cases, leading to colossal number of deaths. This situation is different than what existed a decade ago when pregnant women were seen as not seeking services of a health facility.

Lack of blood transfusion facility, disruptive ambulance services, lack of empathy from staff and unavailability of doctors are reversing the trend, as is evident from data on Janani Suraksha Yojana.

According to an analysis by Centre for Budget and Governance Accountability (CBGA), there has been a steep decline in JSY beneficiaries in the last five years. Devi’s home-state saw a decline of as much as 35.4% from 2010-11 to 2014-15. While in 2010-11, JSY was used by 386354 for pregnancy related services, by 2014-15, only 249455 women were using it. Women in other states are also rejecting the model.  In West Bengal, the decrease has been of 37.1%, in Odisha 6.6% and in Uttar Pradesh it has been 0.7%.

Experiences from the field, as captured by the report, show that public health facilities are equipped to deal only with routine check-ups and deliveries. They are unable to manage emergency situations. To begin with, high-risk women are not even picked up by the health system to take care of during delivery. Devi was aneamic and weak. Her weight was lower than required of a pregnant woman. She had delivered five children before. All these were clear signs of her being high risk. But still, not only the health system did not register her as someone who needs special attention, but could not treat her when she reached the district hospital, with meager support from neighbouring primary health centre (PHC)and Community Health Centre (CHC).

Devi died of heavy bleeding. The child had probably died even before reaching the hospital

In another case in UP, a woman was referred to a CHC by the PHC. The nurse at CHC realised that she needed to be taken to District Hospital (DH). But the woman had to wait till next morning for the doctor to arrive for referral to the DH. By the time doctor at CHC arrived, she had died, leaving her unborn child also dead.

“These are common stories in Azamgarh in UP. Government officials keep saying that there are no maternal deaths, but our experience and data show otherwise,” said Rajdev, who conducted the study in Azamgarh, UP. He was speaking at the national consultation organized during the launch of the report.

Health activists and experts showed their frustration saying that things have not moved in the right direction despite presence of so many schemes, programmes and incentives.

“It is the government’s duty to conduct maternal death reviews (MDR). As civil society, we can only tell them “how to,” said Abhijit Das, director, Centre for Health and Social Justice.

The government is not regular in conducting MDR. Even when it does, data is not made public. There is no analysis based on the reviews to improve or change the situation.

“We need to realize that a pregnancy is not a disease. It is something that can be managed and we all know it is simple. Unfortunately, in the lack of political will, saving women has emerged as a big public health issue,” said senior journalist T K Rajalakshmi, who works with fortnightly Frontline.

Jashodhara Dasgupta from Sahayog, the nodal organization which conducted the study, said, “The report is titled such because the formula of institutional delivery has not worked. Women reached the hospital as soon as they realised that they need care, but the hospitals failed them as they were not ready with the required facilities. Thus, scripts of their deaths were written while drafting policy and their deaths were foretold."

The report also shows that Janani Shishu Suraksha Karyakram (JSSK) --  entitlement to free maternal health services -- does not work at the point of delivery. Violations have been reported from every state from where the case studies have been collected. Often women’s families have had to arrange money for ambulance and expected expenses on diagnostics, medicines, supplies and in some cases informal payments, which led to delay in reaching healthcare facilities. For poor families this is catastrophic and discourages them from going to hospitals the next time.

Failure of the health system in providing something as simple as contraceptive services and counseling kept cropping up time and again in all the regions. A 40-year-old woman in Banda district of UP died during her 12th pregnancy. She had 10 live births and went for induced abortion by consuming pills for the 11th time. As the 12th pregnancy was also unwanted, she went for abortion by similar method. The woman consumed five pills without any proper medical advice. She died in less than 24-hours due to heavy bleeding. Despite reaching a public hospital, she could not be saved.

The public health system is clearly not reaching women for guidance on contraceptives. It is then doubly failing them by not providing access to safe abortion services, even after, like in the present case, they have previous record of abortions. The State’s neglect is responsible for innumerable deaths and morbidity. Behavioural issues of healthcare staff in public health facilities were faced by majority of families interviewed. Coming from marginalized backgrounds, they are not treated as equals by the government staff and this discouraged many women from seeking care in public health facilities.

September 21, 2016

New Delhi, Sep 16 2016
A national alliance of organisations working on maternal health rights today called for setting up of an independent monitoring commission to look at the audits and reports that are commissioned by the government to review its family planning programme.  An oversight body of parliamentarians, women's rights organisations and academicians needs to be constituted immediately, said Jashodhara Dasgupta of HealthWatch Forum U.P, adding that such measures would support Wednesday's landmark Supreme Court order in the case of Devika Biswas vs Union of India and others (Writ petition (Civil) No.95 of 2012), that ruled against mass sterilisation camps and called for greater transparency in the family planning programme. Dasgupta said, speaking at a press conference organised in New Delhi today by the National Alliance for Maternal Health and Human Rights (NAMHHR) and HRLN through whom the petition had been filed, activists from across the country and public health experts welcomed the judgement as an important step towards reproductive health justice for women in India.

Petitioner Devika Biswas  appreciated the order acknowledging the government’s failure  opining at the same time that mass sterilisation camps should be stopped immediately rather than being given a buffer period of three years. She felt government accountability needed to be emphasised through ensuring redressal and compensation for the women who had suffered, which was currently lacking.  "Civil society and media now need to vigilantly monitor the implementation of the SC order by informing communities that the practice is soon to be banned," said Biswas.

"Government accountability needed to be emphasised through ensuring redressal and compensation for the women who had suffered, which was currently lacking.  "Civil society and media now need to vigilantly monitor the implementation of the SC order by informing communities that the practice is soon to be banned."          - DEVIKA BISWAS

Kavita Krishnan, Secretary AIPWA expressed concern at the press conference that the issue was still being framed as  a population control problem rather than a question of reproductive justice for all women. She emphasized,"The question is not about which is the next best technological fix in contraception but about what actions will empower women to gain control over their bodies, and encourage men to take responsibility for contraception."

Described as the single largest operation ever to take place anywhere in the world, equivalent only to the cataract eye surgeries, about 4-5 million women in India undergo sterilisations each year, and the estimate is that close to 1000 women die every year due to the appalling conditions in which sterilisations are carried out by public health system.“The family planning program in India adopted a mass surgery approach in the 1970’s in Ernakulam, Kerala, where men underwent vasectomy by the hundreds. This same approach was applied, however, to the more complicated procedure of female sterilization which involved an abdominal operation, a grossly inappropriate move in hindsight,” said  Abhijit Das, Convener of  NAMHHR.

Sanjai Sharma of HRLN recounted the long struggle of over two decades to highlight concerns about quality of care in sterilization camps. Specifically he referred to the Ramakant Rai v Union of India case, which the present judgment refers to and expressed surprise that the Supreme Court orders in that case from 2005 have not been implemented as yet on the ground.

Ajay Lal of the Maternal Health Rights Campaign in Madhya Pradesh spoke about the  conditions prevailing insterilization camps in the state. He related observations from 28 camps in 12 districts of M.P in 2016, describing that even now camps were  being held in unsanitary conditions in dharamshalas and schools apart from public health centres, and cycle pumps were being used to pump air into the abdomen, a gross violation of standard operating procedures. Rajdev Chaturvedi  from Healthwatch, Uttar Pradesh who is also a member of the quality assurance committee (QAC) in the district of Azamgarh, said that the committee was constituted three years ago but no meeting has been held. He also spoke of emerging issues related to family planning, especially that of fraudulent records of post-partum IUCDs and stealth insertion of IUCDs without women’s knowledge after delivery. From Chhattisgarh Dr Yogesh Jain  ofJan Swasthya Sahayog provided his observations following the Bilaspur incident where 13 women died after sterilization operations in 2014. He mentioned that the Anita Jha commission report which inquired into the matter had not inspired any confidence as it merely shifted the blame onto an external party – the drug manufacturer – even though evidence pointed to the contrary. In response to the case, the public health facilities had altogether stopped conducting sterilization camps and now women who needed the procedure had to go to neighbouring states or pay a private provider to avail of these services. This is an unintended consequence of the issue and ultimately ends up harming women.

The press conference ended with a call to use this judgment as an impetus to launch a larger public movement against  the 'violation of women's bodily rights' by  highlighting  concerns around the implementation of the family planning program with regard to quality of care and informed choice and maintaining pressure on the government for greater accountability.