One woman dies every ten minutes due to pregnancy related complications in India. Although the government has put in place schemes to ensure that every woman has access to healthcare during and after pregnancy, ground reports produced by Video Volunteers reveal that access to prenatal and postnatal care, nutrition and timely medical intervention remain dismal in several parts of the country. Nupur Sonar, Trainer & Mentor at VV analyzes some of the key themes emerging out of the ground reports and why VV decided to launch a campaign on community monitoring of maternal health.

Having a baby in a remote village of eastern Bihar in India means being pregnant with anxiety and a sense of helplessness.  Without access to health infrastructure to monitor pregnancies and provisions for emergency care, it is a life threatening situation for both the mother and the unborn child. In cases of abortions, women who approach state-run health facilities are turned away due to a lack of infrastructure and are forced to approach private practitioners. Most of them cannot afford their services.

Last year, 24-year old Masuhsun Khatun from Fulvari village of Bihar’s Kishanganj district was expecting her fifth baby. She was five months pregnant in June 2014, when she tripped and fell in the front yard of her house.

Later that night, Masuhun woke up writhing in pain and bleeding profusely. Her husband tried calling a government ambulance to no avail. He then hired a private vehicle to get Masuhun to the nearest government hospital. They found no doctors there and Masuhun was taken to a private practitioner, who informed her that she needed to undergo an abortion.

Two weeks after the abortion at a private health facility, Masuhun started bleeding again. This time she was taken to a state-run hospital, where she was told she had foetal remains in her womb. Masuhun was forced to undergo a remedial procedure at her home, under the supervision of an auxiliary nurse midwife (ANM), because the hospital lacked adequate medical facilities; although, ANMs are not qualified to perform surgical procedures. Her condition worsened over the next five days before she breathed her last.

For three weeks, Masuhsun shuttled between private practitioners and state-run medical facilities. Her husband, a daily wage labourer, spent nearly Rs 40,000 on her pregnancy and the subsequent termination, including Rs 17,600 on eight bottles of blood required for transfusion.  

This video report by Video Volunteers Community Correspondent Navita Devi reveals that due to lack of proper abortion facilities, trained medical personnel and access to public health facilities, several other women in Fulvari village of Kishanganj district in Bihar suffered the same fate as Masuhun’s. The ones who survived, live with financial burdens and a trauma that never leaves them.

This, however, isn’t just the story of the women of Fulvari. 

56,000 women succumb to pregnancy related complications in India every year — the highest across the world.  These are entirely preventable deaths, caused by Infections due to non use of a sterile kit during delivery, home births without trained providers, eclampsia, postpartum haemorrhage, early pregnancies, anemia and unsafe abortions are the leading causes of maternal deaths.

VV’s Maternal Health Campaign
In early 2015, VV launched a campaign, with support from Oxfam India, to monitor maternal health in India through the tool of community-produced videos. VV felt there was an urgent need to bring out more community voices on this issue which gets scant media attention. 75 Community Correspondents from marginalised communities across four states – Jharkhand, Bihar, Odisha and Chhatisgarh— were trained to examine gaps in the implementation of maternal health schemes, report on violations and devise solutions to improve the state of maternal healthcare in the country. 

As of July 2015, VV has produced 50 ground reports on maternal health, of which 25 have been produced in the last 10 months. More are in production and will be added to the playlist below. Correspondents are currently executing their impact plans: they are showing the videos to their communities and to officials to resolve the issues highlighted in the videos. With the first set of correspondents now trained to report on maternal health right violations, VV now plans to extend this training to each of its community correspondents from its network of over 180 from across the country.

Read our previous blog about the maternal health training workshop, the Correspondents’ direct experience of maternal health violations, and the impacts Community Correspondents have achieved over the past several years on the issue of maternal health.

WHAT DO THE GROUND REPORTS REVEAL?
An analysis of the ground reports produced so far reveal that the schemes, although promising on paper, fail to reach its beneficiaries. In particular, they shed light on the state of  implementation of the government’s key maternal health program, Janani Suraksha Yojana (JSY). In 2005, the Ministry of Health and Family Welfare launched the (JSY), a cash transfer programme, that incentivised institutional deliveries, in order to reduce maternal deaths in India.  Women are awarded Rs 1,400 in rural areas and Rs 1,000 in urban areas to give birth in public health facilities, under the scheme. It also makes provisions to reduce out-of-pocket expenditure —providing free antenatal check-ups, IFA tablets, medicines, nutrition in health institutions, provision for blood transfusion, and transport from health centres and back. 

The ground reports by Video Volunteers’ (VV) Community correspondents are testament to the fact that despite the introduction of the JSY, access to prenatal and postnatal care, nutrition and timely medical intervention remain dismal in several parts of the country. 

POOR INFRASTRUCTURE & ABSENTEE DOCTORS
Women continue to give birth in deplorable conditions at unhygienic and ill-equipped health facilities. While Bharti Kumari reports on how crumbling infrastructure at a government health facility poses a threat to the life of patients as well as health workers, Mary Nisha Hansda report reveals how pregnant women wait for hours to receive medical attention and are charged not just for medicines but also for using the toilet at the Primary Health centre in Godda. According to the health ministry guidelines a Primary Health Centre is supposed to have two doctors. However, no doctor was present at the time when Paku Tudu was brought in to the hospital. Her delivery was conducted by an ANM.

NO AMBULANCE SERVICE & OUT OF POCKET EXPENDITURE 
50% of the stories report on instances of out-of-pocket expenditure and the absence of ambulance service in villages. For instance Gyanti Kumari report from Bihar’s Siwan district on the shortage of medicines at the Rajapur Primary-health centre and instances where women were forced to spend money on medical facilities they are entitled to under the JSY.  Her report reveals that an auxiliary nurse midwife charged a pregnant women Rs 50 per injection and Rs 500 to cut her umbilical cord.

MISSING INFRASTRUCTURE & HEALTH WORKERS
While India’s public health system grapples with a dearth of health facilities, shortage of human resources is one of the biggest impediments to the functioning of existing public health facilities in India. The absence of a health centre nearby also means that pregnant women have to travel long distances to avail medical services. Several testimonies reveal that many women cannot afford traveling to faraway clinics and forego check-ups altogether. 

In interviews to Reena Ramteke, several women from Khatti village in Chhattisgarh say that  ANMs hardly ever visit the village, and that the sub-health centre in the village always remains locked. A sub-health centre is a state-run first care provider staffed by an ANM who is responsible for administering antenatal care to pregnant women.  

FRONTLINE HEALTHWORKERS DRIVEN INTO THE GROUND
Frontline health workers are often blamed for dismal healthcare in rural India. However, they are spread too thin and are forced to work under inhuman conditions. According to the ministry guidelines, one ANM is supposed to look after eight sub-health centres. However, in Jharkhand’s Dhanbad district, two ANMs look after 23 centres in Baghmara block. Ahilya Devi looks after 14 of the 23 centres.

“There is no water and provisions for emergency light in cases of power failure. In such a case we have no choice but to use a flashlight, lantern or candle. How do we put stitches in such a case?” she asks. She admits that because of the workload, she often can’t make it to some sub-health centres.

NO CASH INCENTIVES
Instances of women not receiving cash incentives promised under JSY are endemic across rural India.  Satyanarayan Banchor, reports on one such instance from Bankheda village of Bolangir district in Odisha. “ Why should we deliver at public health institutions when we neither get quality care nor incentives that we are entitled to,” they ask.

WHY DO WOMEN OPT OUT OF GOVERNMENT SCHEMES?
In testimonies to VV’s community correspondents, women say that  the lack of infrastructure, support from healthcare providers and high out of pocket expenditure discourages them from seeking care at state-run facilities. Unavailability of or delay in the arrival of an ambulance is another deterrent. 

In a bid to combat maternal and neonatal deaths, the health ministry plans to launch Kilkari, a project through which voice messages delivering advice to pregnant women to increase health awareness amongst them will be sent out.  The launch of the project however, has seen some back and forth. Although this might prove to be a cost-effective way of spreading awareness, what about safety of women who choose to deliver at public health institutions? How far will awareness campaigns take us at a time when the public health system is in complete disarray?