Status of Maternal Health Services- A Report

By Centre for Health and Social Justice (CHSJ)
 and National Alliance for Maternal Health and Human Rights (NAMHHR)

To strengthen the maternal health services in the country government has taken various steps such as fix day services, care to pregnant women identified with some kind of risks, cash incentives and free transport facility for childbirth in the health facility, mandatory stay for 48 hours at the institution etc.

Centre for Health and Social Justice (CHSJ) and National Alliance for Maternal Health and Human Rights (NAMHHR) in collaboration with state networks in five states [Health Watch Forum in Bihar, Jharkhand Women's Health Network, Dalit Human Rights Forum-Karnataka (KR), Maternal Health Rights Campaign, Madhya Pradesh (MP), Health Watch Forum- Uttar Pradesh(UP)] carried out community based monitoring (CBM) of maternal health services in 2019.  The CBM tools were developed based on the health services entitlements promised under the programs and as per the Indian Public Health Standards. Real time data was collected using mobile application namely 'Swasthya Darpan'. Women who had childbirth in last six months were interviewed for their childbirth experience;  Village level fixed day services and Primary Health institutions were observed for the status of maternal health services. Please see following table for the details: 

State	No. of Districts	No of Villages	No of women	No of CHC	No of PHC	No of SC	No of VHND
Bihar	5	58	233	14	17	52	45
JH	5	46	201	15	15	16	44
KR	7	93	213	10	24	54	85
MP	7	111	237	20	25	46	47
UP	10	52	234	16	16	23	50
Total	34	360	1118	75	97	191	271

Village Health Sanitation and Nutrition Days (VHSND)

VHSND, a monthly designated day in the village for carrying out various health related activities among which one of them is providing maternal health services to pregnant and lactating women. It is envisaged to be an inclusive and comprehensive space for catering to pregnant women’s care by administering a range of services. A VHSND is successful when it fulfils its objectives to ensure that women are given timely services with utmost care. However in the current scenario the story is otherwise. The CBM activity looked into three aspects of the VHSND namely human resource, infrastructure and services administered. Each of these categories had a range of relevant components that needed to be available for better functioning in the given domains. Each of the observed components then weregiven a score of 1 if available or as required by IPHS standards and 0 if not available. The scores were then converted into scores cards in the specific domains. The status of the VHSND in the various states is as follows:

Table 1: Score percentages of the available components at the VHSND [≤50 score %= Poor(Red); >50 and ≤80 score %= Satisfactory (Yellow); >80 score % = Good (Green)]
State	Human Resource (%)	Infrastructure (%)	Services (%)
Bihar	56.8	31.1	52.3
JH	61	41.5	43.5
KR	51	35.8	47.9
MP	87.5	53.1	48.6
UP	97.2	54.9	59.9
Total	68.9	42.8	50.1

• From the data collected, we see that the VHSNDs are still not functioning in the way as desired.
• In the states of Bihar, Jharkhand and Karnataka, the availability of the Human Resource (ANM) status is only satisfactory as many of the ANMs are not present throughout entire day.
• Across all the states, it is evident that even though the ANM is present in person, the status of the infrastructure and services is mostly in poor conditions.
• Most of the VHSNDs across the states have taken place without ensuring the minimum required infrastructure and services available.
• In Bihar services status was in the satisfactory category whereas infrastructure was highly poor with only 31% score percentage of the services present in the VHSND.
• IN Jharkhand and Karnataka both the services and the infrastructure in the VHSND were in the poor category.
• In MP, the human resource fared better, but infrastructure was only 51% score percentage and services worse with 48.6%.
• IN UP, human resource was adequately available with 97.2% score percentage, but services and infrastructure fell into the satisfactory category with both falling only slightly above 50% score percentage. 

Ante Natal Care (ANC) Services

•          Overall antenatal care services is in very poor condition across the four districts
•           Receipt of 1^st ANC in first trimester- Early registration leads to early care and prevention. Not all women were registered in the first trimester. Around 30% were registered after the 1^st trimester.
•           Minimum ANC check-up required is four for every woman, however, only 24.2% of the women had 4 or more ante natal checkups, 26% had 3 check ups and around 50% had only 2 or lesser check-ups. Except in Karnataka, where less than 50% women had a full four ante natal check-up. In Bihar and Jharkhand, the proportions are abysmally low with less than 10% women receiving 4 ANCs which defeats the whole purpose of reducing maternal morbidity and mortality.

Status of services provided during ANC:

Table 3: Proportion of women received ANC services
State	≥ 3 BP check up	≥ 3  Hb test	≥ 3  Urine test	≥ 3  Abdominal check	100 IFA tab
Bihar	10.3%	6.4%	5.6%	11.6%	87.1%
JH	16.4%	5.5%	5%	13.9%	71.6
KR	92%	88.2%	46.4%	81%	93%
MP	48.5%	42%	30.8%	30.9%	83.1%
UP	35.8%	38.8%	21.4%	37.2%	77.8%
Total	40.5%	36.2%	22.9%	34.8%	82.6%

• Across all the states, from among the ante natal tests and checkups, most of the women received Iron Folic Acid Tablets during the pregnancy period. Other tests were not received as per the minimum mandated standard. It jeopardizes the purpose of early detection of risks or to monitor the improvement in health of the pregnant woman.
• Across the 4 states, leaving Karnataka, less than 50% of the women received the mandated check-ups of blood pressure, haemoglobin, urine tests and abdominal examinations. In the states of Bihar and Jharkhand, the situation is very poor with less than 20% women receiving three or more check -ups.

Place of delivery

As a result of consistent and multidimensional approach of the government significant no. of births have happened in an institution- around 69% in a government facility and around 14.2% in a private facility. Of all the births taken place, around 15% took place at home; few births took place while on the way to institution.

Experience in the Labour Room

Although govt. Encouraged women to come to the health institution for the childbirth but still Privacy, respect and dignity for the woman in child birth to get there yet seems to be a remote dream as seen in the table below:

• A large proportion of women across the states reported having been touched inappropriately while in labour, in UP, MP and Bihar it was more than 50%.
• Except MP, in all the states, a small proportion of women were physically abused, verbally abused and passed undignified comments.
• Birth companions were not allowed in the labour room. In Bihar and UP, 40% of the women reported birth companion not allowed, In Jharkhand and Karnataka it was higher with 60.6% and 73.7% respectively.
• The influx of other people into the labour room was also common, mostly in Bihar, Karnataka and UP.

Table 4: Behaviour experienced by women in the labour room
State	Entry of other people	Companion not allowed	Physical Abuse	Verbal Abuse	Inappropriate touch	Undignified comments
Bihar	25%	43.7%	2.9%	6.9%	50.6%	1.1%
JH	2.8%	60.6%	1.4%	3.5%	36.6%	3.5%
KR	14.8%	73.7%	1.4%	1.9%	23%	.5%
MP	4%	36.3%	0	0	59.7%	0
UP	32.5%	40.4%	2%	1%	57.1%	5%
Total	16.6%	50.7%	1.5%	2.5%	45.6%	1.1%

Out of pocket Expenses

• Of those who had institutional births (954), 88% had to shed money from their own pockets.
• Of those who had some out of pocket expense, around 22.3% spent more than Rs5000, 13.4% spent between Rs. 2001- Rs 5000, 63.4% spent Rs 2000 or lesser  which raises question on free availability of childbirth services!

Ambulance Service

•           Free ambulance service to go to the institution was received only by 32 % of the women; while for for returning home, lesser women, around 19.8% only received free ambulance.

     Post Partum Care 

      A comprehensive maternal care is not complete without providing care after the childbirth. Many women die post child birth or develop some kind of complications. Even though health workers are supposed to make regular visits to the woman’s house, we see that the situation is in an unsatisfactory state.

• A huge proportion of 44% had just one or no visit by the health worker
• Around 49% had a health worker visit 2-4 times post delivery
• Only 6.9% of the women had a health worker visit 5 times or more after delivery

Receipt of the maternity schemes

Janani Suraksha Yojana (JSY)

Table 3: JSY Scheme availed by women
State	Received JSY	Paid bribe to receive(n=those who received)
Bihar	33.8%	54.4%
JH	8.9%	22.2%
KR	26.8%	0
MP	46.2%	2.7%
UP	37.2%	24.1%
Total	31.3%	20.1%

• All eligible women did not receive the JSY fund. More than 50% of the women in Bihar had to pay bribe to avail the JSY scheme. IN JH, MP and UP, around 20% of the women had to pay a bribe to get the money. 

Overall situation throws challenges to address the grey areas like continuity of care, quality ANC and PNC, Care with respect and dignity and free childbirth services and timely receipt of the maternity entitlements promised under various schemes and programs. To achieve the sustainable Development Goal (#3) it is important to ensure the continuum of care and quality maternal health services.