A mother’s nightmare that is Bihar

Ritu Bhatia | Updated on January 16, 2018

Health matters Bihar must ensure safe deliveries   -  Ranjeet Kumar

A health policy that overemphasises ‘infrastructure’ leaves untouched the appalling state of mother and child care

One factor that is totally ignored in all deliberations on women’s empowerment is the role of high quality healthcare. Education, jobs and bank accounts remain the thrust areas of rural empowerment programmes, which leave sanitation, hygiene, family planning and safe motherhood out of their strategies.

Take the case of Bihar, hailed for the recent government initiatives taken to boost the status of women: Mukhyamantri Nari Shakti Yojana, 50 per cent reservations for women in local Panchayati Raj bodies, the introduction of a 35 per cent reservation for women in government jobs in the state, and so on.

Indeed, these are great schemes, especially for Bihar, which fares poorly on gender parity, according to The McKinsey Global Institute new report of November 2015, ‘The Power of Parity: Advancing Women’s Equality in India’. The female literacy rate of 51 per cent is the lowest in the country, as is the female work force participation rate (FWPR) of 90 per 1,000 women employed (SRS, national crime records bureau).

Hopes of change were high, when the seven-point agenda or nischay for Bihar was released by the Chief Minister Nitish Kumar nearly a year ago. Radical improvements were promised on several fronts, though health was missing from the main agenda; only health infrastructure got a mention and indicators such as the nutritional status of women, or number of maternal deaths didn’t feature.

In bad health

Today, the repercussions of this glaring oversight are obvious. Too many girls and women in Bihar suffer from under-nutrition, too many die as a consequence of pregnancy and childbirth, and too many lack access to high-quality, life-enhancing healthcare.

Attempts to curb early marriage have faltered: 25 million girls in the state still marry between the ages of 10-19 years. Only one out of every three uses contraceptives.

Of the three million women who get pregnant every year, 6,500 die from complications: heamorhage, infection, obstructed labour, hypertensive disorders and other underlying conditions that include anaemia. ‘Too little too late care’ is the adage aptly used to describe maternal health care in regions such as Bihar, in the new 2016 Lancet Maternal Health series.

Ignorance, delays and shortages characterise maternal health care in the state: poverty, ignorance about healthy pregnancy and delivery, lack of proper transport to and fro from facilities and lack of access to timely emergency obstetric care. Public health facilities that serve as First Referral Units (FRUs) still lack basic infrastructure, specialist doctors, and medicines to tackle maternal emergencies.

Mission not accomplished

Nearly 45,000 women in India still die of pregnancy related causes every year, contributing to 15 per cent of the global maternal mortality, says the Lancet report. Though maternity care coverage has increased in the past 25 years, one fourth of all pregnant women still don’t have access to a skilled birth attendant and quality health services.

India’s flagship National Rural Health Mission (NRHM) was launched in 2005, with the intention of improving healthcare in under-served areas. A thrust area of the national Reproductive and Child Health Programme (RCH-II) was to strengthen emergency obstetric care, by upgrading infrastructure at rural First Referral Units (FRUs)— community health centres, district hospitals, referral hospitals etc. Official guidelines mandated one FRU for every 50,000 people. Based on this estimate, Bihar needs 208 FRUs to serve its people (census 2011). Today, more than 10 years after this directive, the state has only 66 functional FRUs.

Data from the CAG report on General Social and Economic Sector, for year ending in March 2015, shows that the number of institutional deliveries remained almost static over a five year period. Ironically, home deliveries had tripled.

The reasons more women opted for home births were: lack of health facilities with requisite infrastructure, shortage of trained medical personnel including nurses and midwives, and high out of pocket expenses for deliveries.

Despite the existence of the JSY scheme — which entitles women who deliver in FRUs a cash incentive of ₹1,400 in rural areas to cover out of pocket costs — the average spend of a family was 1,724 rupees, since only half actually claimed their entitlement.

Unsafe deliveries

The promise of ‘safe’ institutional deliveries was false too: Even though 64 per cent of women opted for institutional deliveries in Bihar, half left the public health facility within eight hours of delivery, and one fourth left within four hours, says a Bill and Melinda Gates Foundation backed study that noted institutional gaps in staffing, equipment and hygienic practices. Chances of developing post-partum complications in the 24 hours after delivery are high, so being discharged from a hospital too soon after a delivery is risky.

“Leaving no one behind” is the noble mission of the Sustainable Development Goals (SDGs) that focus on equity. But the chances of meeting this goal remain slim, unless more tangible measures are taken to improve access to complete maternal health services.

A holistic approach to women’s health is the need of the hour: good nutrition, safe contraceptive options, healthy pregnancies and safe deliveries for every adolescent and adult in the state. Strong governance and political are essential to build a robust health system with the capacity to every woman the healthcare she deserves.

Ultimately, India can only hope to reduce its maternal mortality rate from the current figure of 167(SRS 2011-13), to the SDG target of 70 deaths per 100,000 live births, if Bihar gets its act together.

The writer is a microbiologist who specialises in writing about health issues

Published on October 18, 2016

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