Hospital Births: Village Dai, ANM, and Women Folk’s Response
(Gurdarshan Singh)*
The optimum use of health facilities in ideal conditions depends on the
availability, quality, and access to the common people. Functional aspect, however,
suggests that management is equally important for maintenance and efficient delivery
of services. The community response, nevertheless, to avail off the services, among
various socio-economic groups though differs considerably, is also crucial for the
optimum utilisation of services.Despite the uniformity in the programme design
throughout the country, there is considerable regional disparity in the availability and
quality of health services, including maternal health services, noticed a recent report.
In the brief review of literature, the report concluded that the previous research
provides conflicting evidences on the relative importance of programmatic (supply),
and non-programmatic (demand) factors effecting health-seeking behavior (NFHS,
2000).The policy planners in the past have suggested ‘comprehensive package’ to
optimize the utilisation of primary health care. This premise unequivocally is the
precondition in the beginning of any programme. Though, the assessment of the
programme at the premature or mature phase gives vent to enlarge the scope of the
services suggesting various other functional positions on priority basis.
In the present endeavor, an attempt has been made to analyse the extent of
institutional deliveries with specific reference to the community response, to
underline the trends in the utilisation of health care services. In this context, a bunch
of studies views that despite desirable socio-economic progress, people especially in
rural areas still have reluctant attitude to avail off the health care services in a
restricted manner owing to their customary beliefs, in particular, and prevailing
specific socio-economic conditions, in general. An other view suggests that large
number of these facilities/ services such as health etc., in fact, are functioning without
taking note of changes taking place in rural areas. With the result, common
man/woman’s access to these facilities has become difficult. Also, the importance of
*
Population Research Centre, Panjab University, Chandigarh.
maintaining adequate link with the people in an area without considering needy
households losing out on new opportunities for proving these facilities. On the other
hand, at the empirical plane, as there are substantial evidences show that inadequate
coverage of population conceivably the direct consequence of the poor health care
infrastructure and delivery services leading to people’s unceasing reliance on unsafe
delivery i.e. home delivery, what is still enormous, and the results are problematic.
Family Welfare Programme - Brief Background
An official Family Planning Programme commencing in the First five-year
Plan in 1952 with a clinical approach, the programme took wings in the Third fiveyear Plan with the adoption of the Extension Education approach in 1962. In 1965,
United Nations Advisory Mission suggested the launching of what was called the
Reinforced Programme, the major component of which was an energetic loop
programme (Roa, 1994). At the same time, at the empirical plane, it was realized that
there exist large gaps in reaching the target population resulting into the poor
performance of the Family Planning Programme. Consequently, the population
stabilization programme has set priorities for the achievement of goals with in
specified period. Organisation restructuring, mobilisation of resources, and population
coverage were some of the priority areas being considered in the programme
formulations. Among all these priority areas, for effective population coverage,
provision of infrastructure facilities, health manpower requirements, and package
programme are the core sub areas emphasised during last three decades.
To improve the coverage, Kartar Singh Committee (1973) had recommended
the “integrated approach”, bringing together health, family planning, and mother &
child health care components of the primary health care. Under this approach, MultiPurpose Health Workers (MPHW) Scheme was introduced. The MPHW scheme has
brought about progressive changes to improve the number and quality of basic health
workers.
The Draft Fifth five-year Plan had captured the essence of the “integrated
approach” which said that the ‘minimum needs programme along with the training of
Multi- Purpose Auxiliary and a more vigorous pursuit of communicable diseases
eradication/ control is the core of the health care programmes’ (Special
1
Correspondent, 1976). At the end of the Fifth Five Year Plan (1978), it was realised
that the rural population coverage is still of no consequence. With the result,
progressive changes have been introduced in the programme over the sixth and
seventh five-year Plans periods when national norms for population coverage were
adopted. During Eighth Five Year Plan, the emphasis was mainly on consolidation of
the existing health infrastructure rather than expansion. (MHFW, 1996)
In addition, the package programme with in the purview of “integrated
approach” laid considerable emphasis on mother & child health care (MCH). One of
the basic objectives of MCH care is ‘to provide prenatal care for all women, to have
all births either in the hospital or attended by a trained health worker, to identify
pregnancies where the risk is high, and provide special care for those mothers and
infants’. In practice, the reduction in maternal and infant morbidity, and mortality
through MCH interventions is highly imperative to accomplish the set goals in the
Family Welfare Programme.
In the recent past, the “expanded MCH Programme” under the RCH
(Reproductive Child Health) on pilot project basis, concerted efforts have been made
to decentralize the health care in urban areas on the pattern of three tier rural health
care system. And, spelled out again the health package programme on the basis of
community needs. The reassertion of earlier priorities more specifically formulated on
the basis of community needs once again has underlined the necessity of population
coverage under the primary health care. With the result, the role performance of the
basic health worker became very important.
In early 1970’s, the workload at each sub centre was double i.e. on an average
a population of 20,000 was looked after by one ANM. At the rate of 40 births per
1000 population 800 deliveries would have taken place, in the jurisdiction besides the
family planning work. It is considered that even 10,000 population is too much to be
covered by 1 ANM. The ideal would be 1 ANM for 5,000 population for combined
MCH and family planning work (IIPA, 1971). If not complete according to the
national norm adopted, in the year 2001 the coverage has certainly improved.
2
Data Sources:
The Ministry of Health and Family Welfare, initiated Rapid Surveys for monitoring
the implementation of the “expanded MCH” (RCH) programme. In this scheme of
things, PRC, in consultation with the Director General of Health Services, Govt. of
Haryana and Regional Director, Ministry of Health and Family Welfare selected
districts of Kurukshetra and Kaithal in the first phase. In the second phase district
Rohtak, Faridabad, and Jind were selected. Rapid Surveys are to be conducted in all
the districts of Haryana in a phased manner. But latter on, in the second phase the
Ministry discontinued the Rapid Survey, and replaced them with the Nation- wide
RCH district surveys.
Data for the present paper has been drawn from the Rapid Surveys conducted in
Rohtak, Jind, Kurukshetra, Kaithal, and Faridabad districts of Haryana.
Table1 Districts, Villages covered and Eligible Women interviewed in Rapid
Surveys.
District
Survey Date
Sub-Centre
Villages
Non-Sub-Centre
Villages
Eligible Women
(15-44 age)*
Rohtak
February, 1998
22
19
1006
Jind
May, 1998
20
19
1019
Faridabad
Kurukshetra
Kaithal
January, 1999
February 1997
April 1997
18
24
25
19
18
20
1066
732
733
*The
Eligible Women interviewed were those who had given birth to a child during last two years
period prior to the survey. For instance, in Faridabad district, the survey was conducted in the month of January
1999. And the woman who had given birth(s) to a child between January 1997 to December 1998 was interviewed.
Data Analysis and Discussion
Role of Auxiliary Nurse Midwife for providing ANC: In addition to several other
aspects, the rapid surveys in five districts also collected information on the role
performance of Auxiliary Nurse Midwife (ANM) during specified period prior to
survey. In Faridabad district alone, during last pregnancy the proportion of women
who met the ANM at home or at Sub centre is 78.0 percent. The mean duration of
pregnancy of women at the time of first contact with ANM is 5.2 months. Nearly 62.0
3
percent of women came into contact with the ANM during last trimester of the
pregnancy. Thus, though the overall coverage of pregnant women by ANM through
contact at home or Sub centre is satisfactory (though not complete), this contact is
rather late in the pregnancy. Furthermore, during the duration of pregnancy three
ANM- pregnant women contacts for ANC are mandatory. Here too there is
considerable shortfall- the mean number of contacts comes to 2.2. The ANM contacts
with the pregnant/eligible women seems to be insufficient parameter to underline the
effective coverage under the “expanded MCH Programme”.
During the period of gestation a woman must have three check ups. She must
undergo routine medical check-ups like blood pressure, urine test, Hb count. Also
women are required to get two Tetanus Toxoid (TT) injections and iron & folic acid
(FA) tablets. The findings in Rohtak district reveals that nearly 20.0 percent women
had TT injection, FA tablets, and routine check-ups. While, 67.8 percent women had
TT & FA tablets but no routine check-up. In Jind district, only 9.5 percent women had
TT, FA, and routine check-up. And, 76.9 percent women had only TT & FA tablets.
In Faridabad district, a majority, 98.5 percent women had received TT injection, and
68.7 percent had FA tablets. In case of TT & FA tablets combine together, this
percentage comes to 68.0. When, medical check-up is also added to (TT+ FA) this
percentage sharply shrinks to 18.0. Interestingly, in Faridabad, the proportion of
women who had received ANC service from private sector was negligible.
The survey results of Kurukshetra district show that ANMs advised only 30.0
percent women to go to the hospital for delivery and 70.0 percent women reported
that they were not advised to go to PHC/ hospital for delivery. Among the women,
20.0 percent were suffering from various problems during last pregnancy- out of
these, half of them were advised to go for institutional delivery, and the remaining
women having problems were not advised by the ANMs to go to hospital for delivery.
In Kaithal district, ANMs advised 18.0 percent women to go to the hospital for
delivery and the remaining 82.0 percent women reported that they were not advised to
go to PHC/SC/ hospital for delivery. Among the women, 20.0 percent women
suffered from one or the other problems during the last pregnancy- out of these, only
one-third of them were advised to go for institutional delivery and the remaining
women having problems were not advised by the ANMs to go to the hospital for
4
delivery. In Faridabad district, only 6.0 percent women in our sample report receiving
advice from ANM to go in for institutional delivery. On the part of ANM this appears
to be an area of gross neglect.
Hospital Births: In order to measure the effective coverage, another parameter namely
hospital births has been analysed as follows.
Apart from other factors, the efficient functioning of health facilities also
depend on the skill in-put, viable referral system, follow-up arrangements, and well
equipped facilities at referral units. Ideally, the deliveries need to take place in health
institutions under the supervision of trained medical personnel. To a large extent this
would ensure safe delivery-- safe motherhood, and child survival. Also any
complication at the time of delivery both for the mother and the child can be best
attended to in a health institution.
Table 2 District-wise distribution of women by place of delivery
District
Home based
Hospital based
Public sector
Private
Rohtak
807 (80.2)
199 (19.8)
133 (66.8)
66 (33.2)
Jind
865 (84.9)
154 (15.1)
70 (45.5)
84 (52.5)
Faridabad
849 (82.27)
183 (17.73)
56 (30.60)
127 (69.40)
Kaithal
599 (81.7)
134 (18.3)
27 (20.1)
107 (79.9)
Kurukshetra
506 (69.2)
226 (30.8)
26 (11.5)
200 (88.5)
Data presented in Table2 show that except Kurukshetra (30.8 percent), in all
the remaining four districts, the deliveries took place in a hospital ranged between
15.7 percent to 19.8 percent. In Kurukshetra, a majority, 88.5 percent women had
gone to private homes. Followed by Kaithal (79.9 percent), Faridabad (69.4 percent),
and Jind (55.5 percent). Among all the five districts, only exception is Rohtak, where
66.8 percent women had availed off the public sector facility. Table 2 further reveals
that 80.0 to 85.0 percent home deliveries in four districts took place at home.
Whereas, in Kurukshetra district, 70.0 percent deliveries took place at home.
5
Table3 Assistance received by women during home delivery
District
Untrained Dai
(UNTRAINED
DAIS)
Trained Dai
(TRAINED
DAIS)
ANM
Others
Use of DDK
Rohtak
215 (26.8)
528 (65.4)
41 (5.1)
25 (2.7)
298 (37.0)
Jind
266 (30.8)
558 (64.5)
16 (1.8)
25 (2.9)
152 (17.6)
Faridabad
355 (41.8)
437 (51.4)
24 (2.8)
33 (3.9)
195 (23.0)
Kaithal
237 (39.6)
266 (44.2)
66 (11.1)
30 (5.0)
355 (59.2)
Kurukshetra
156 (30.9)
304 (60.1)
45 (8.9)
1 (0.01)
293 (58.0)
TBA-Traditional Birth Attendant (Untrained). TRAINED DAIS-Trained Dai
Role of Village ‘Dai’ and Auxiliary Nurse Midwife (ANM): The traditional birth
attendant is called ‘Dai’. Recognizing the importance of the role of ‘Dai’ and keeping
in view the fact that health workers trained in modern system of medicine were not
only scarce also have other functional problems. The health department, therefore,
undertook to provide training to these traditional birth attendants. Thus, we have two
categories of ‘Dais’, the Untrained ‘Dai’, and the Trained ‘Dai’ (Rapid Survey).
Table 3 reveals that the Untrained Dais in rural areas of Faridabad district, carried out
41.8 percent home deliveries, followed by Kaithal, where 39.5 percent home
deliveries were conducted. In the remaining three districts, the home deliveries
conducted by the Untrained Dais ranged between 26.8 percent to 30.9 percent .On the
other hand, the role of Trained Dais is substantial in conducting home deliveries. The
Trained Dais has replaced the diminishing role of Untrained Dais. Data show that in
Rohtak and Jind districts almost an equal percent of home deliveries was conducted
by the Trained Dais—65.0 percent. In Kurukshetra district 60.0 percent, Faridabad
51.4 percent, and Kaithal 44.2 percent, the Trained Dais conducted home deliveries.
Data, however, further, show that ANMs have had played marginal role in conducting
home deliveries-- the percentage of home deliveries conducted by ANMs varies from
11.0 percent in Kaithal district to 1.8 percent in Jind district. Data also show that the
infrastructure facilities in rural sub-centres for delivery has not been adequate and
there is no referral system exists at the PHC level. In nutshell, the Trained Dais has
become an integral part of the rural health care system and has shadowed the very
existence of Sub-centre infrastructure facilities, and health manpower. The sustainable
growth of Trained Dais in the rural areas logically is attributed to fact that the women
6
folk working as Dais are belonging to the same Village Community and traditionally
it’s a family occupation, mainly confine to the lower caste groups.
Data presented in Table 3 also relates to the use of Disposable Delivery Kits
(DDKs) at the time of birth seems to be the reliable indicator of the level of
involvement of trained health workers/ANM including Trained Dais. In Kurukshetra,
Kaithal, and Rohtak districts, the use of DDKs in case of 59.2 percent, 58.0 percent,
37.0 percent deliveries, respectively, in relative terms, highlight the role of ANMs
accompanied by the Trained Dais in conducting home deliveries. Whereas, in
Faridabad, and Jind districts, the DDKs were used only for 23.0 percent, and 17.6
percent home deliveries, respectively, where the role of ANM was also found to be
negligible. Even though the role of ANM is statistically not significant, but still one
find that there is a positive association between the use of DDKs and percent of
deliveries conducted by the ANMs.The Traditional Birth Attendants/ Trained Dais on
one hand and ANMs on the other are co-existing in the rural areas in conflictresolution situation. The intervention by the health workers especially by ANMs with
the package of services has certainly paved the way for Family Welfare Programme,
but in a restricted manner. The trained ‘dais’ has replaced the diminishing role of
traditional birth attendants/Untrained Dais. This continuity and change can be
explained in the given rural power relations.
Community Response: It can be hypothesized that literate/educated people
would respond more positively to antenatal care, hospital births etc than illiterate
people especially in the rural areas. To be precise, the hospital births are positively
correlated with the education of husband and wife. Data presented in Table 4 relates
to distribution of hospital births according to the education of wife. The survey results
have been analysed as follows.
In Faridabad district, 30.9 percent women respondents were literate. Among
the literate women, 8.7 percent had education up to high school and above. In
Faridabad district, 40.0 percent of the women with high school education gave birth in
the Hospital. Followed by 21.0 percent women who are either literate or have middle
school education. Whereas, 13.9 percent illiterate women had delivered the child in
hospital. Interestingly, an overwhelming number of literate and educated women had
7
availed off the private health facilities. In other words, the proportion of women who
had availed off the private health facilities consistently increases with the increase in
the level of education.
In Rohtak district, the literacy rate is relatively higher than other two districts- 60.5
percent women were literate. And 23.0 percent women respondents have had high
school and above education- out of these 33.8 percent women with high school
education and 20.6 percent women with Literate/middle School education had
delivered the child in hospital. While, only 10.8 percent illiterate women had given
birth in hospital. In relative terms, nearly 66.8 percent respondents with slight
variations according to educational level, had availed off the public sector health
facilities.
Table 4 Place of Delivery and Education of Respondent
District
FAR
ROH
JIND
Illiterate
Lit +
Middle
Matric+
Total
Home
614 (86.1)
181 (79.0)
54 (60)
849(82.3)
Hospital
99 (13.9)
48 (21.0)
36 (40)
183 (17.7)
Public
36 (36.4)
14 (29.2)
6 (16.7)
56 (30.6)
Private
63 (63.6)
34 (70.8)
30 (83.3)
127 (69.4)
Total
713
229
90
1032
Home
354 (89.2)
300 (79.2)
153 (66.2)
807 (80.2)
Hospital
43 (10.8)
78 (20.6)
78 (33.8)
199 (19.8)
Public
27 (62.8)
57 (73.1)
49 (65.3)
133 (66.8)
Private
16 (37.2)
21 (26.9)
26 (34.7)
66 (23.2)
Place
Total
397
378
241
1006
Home
543 (89.3)
243 (80.4)
88 (73.3)
865 (84.9)
Hospital
65 (10.7)
57 (19.6)
32 (26.7)
154 (15.1)
Public
30 (46.2)
24 (42.2)
16 (50)
70 (45.5)
Private
35 (46.2)
33 (57.9)
16 (50)
84 (55.5)
608
291
120
1019
Total
In Jind district, about 40.3 percent women respondents were literate. And 11.5
percent women had high school and above education. Out of these, 26.7 percent
women with high school & above, and 19.6 percent literate & middle pass women had
delivered child in hospital. Whereas, only 10.7 percent illiterate women had given
birth in the hospital. The educated women had registered moderate response i.e. half
8
of the educated women had availed off the public sector health facilities. And, the
other half had gone to the private clinics. While, 57.9 percent literate and middle pass
women had gone to private clinics, and somewhat similar trend in case of illiterate
women has been recorded.
Although, the educated women’s response have had registered much
variations in the utilisation of health facilities in all the three districts. Yet, the
dominant response towards private maternity homes has shadowed the very existence
of public sector health facilities especially in the rural areas. In Rohtak district, a
majority of the respondents both illiterate and educated were inclined towards public
sector health facilities. The reasons are not clear. This aspect in Rohtak, and partly in
Jind districts needs to be explored. As discussed above, in Kurukshetra (88.6 percent),
Kaithal (79.9 percent), and Faridabad (69.4 percent) districts, an overwhelming
number of women had gone to the private maternity homes. The private clinics and
maternity homes are coming up in nearby towns and cities to serve the urban as well
as the rural hinterland. In other words, the private clinics, however, relatively
speaking, are attracting the educated vis-à-vis privileged class.
Summary:
There are substantial evidences exist in the related research works which show
that the reduction in the maternal and infant morbidity and mortality is imperative
through RCH interventions as well as for smooth functioning of the Family Welfare
Programme. One of the intrinsic parts of the recently ‘expanded MCH package’ is, to
have all births either in the hospital or attended by a trained health worker and to
focus on the high-risk pregnancies. Institutional delivery is nevertheless desirable, in
as much as it reduces the risk of both maternal and infant mortality maintains a recent
report (NFHS 2000).
At the empirical plane, with the introduction of Multi-purpose health Workers
Scheme the role of basic health Workers especially of ANMs became very important.
In the present context, the role of basic worker raises an important question i.e. Why a
few births have either been taking place in the hospital or attended by the trained
health personal? The answer to this question in the light of recent trends prevailing in
the health care services reveals the fact that the restricted intervention by the role
9
performance of ANMs with the comprehensive package programme has certainly
paved the way for Family Welfare Programme. The process of training of Dais
slowly and steadily has been replacing the traditional birth attendants. Although the
ANMs and traditional birth attendants both trained and untrained are co-existing in
conflict-resolution situation. Yet, this position has restricted the role of trained health
workers especially of ANM in the rural setting. In other words, both modern and
traditional welfare institutions are co-existing in conflict-resolution situation. This
process can not be explained without going in to the question of power relations.
The analysis of data regarding women’s response, in particular, has
underlined the growing demand for health care especially of private services. The
growing “private emancipation” is nothing but is the
“extension of social
Darwinism”. In other words, the growing socio- economic privilege and private health
care service are going hand in hand. With the result, large number of private clinics,
and maternity homes are coming up in near by small town and cities, which are
serving urban areas as well as the rural hinterlands. The private clinics are not only
well equipped but have been providing desired services with efficient referral system.
Maternal physical health problems especially of those undernourished mothers
have been recognised, as most vulnerable group needs interventions for better
perinatal and neonatal care. Growth is the best indicator of nutrition status; i.e. it is
more reliable than laboratory or clinical sign. Shortness of stature in the whole child
population is likely to be due to nutrition-infection factors rather than to genetic
differences. Intervention measures related to nutrition and behavioral factors should
start as early as possible in childhood, and adolescence and continue in pregnancy
(WHO, 1976). The policy planners at all levels have realised the importance of
interventions of the kind suggested by WHO and necessity of programmes to improve
the condition of the masses living in abject poverty. At the empirical plane, the
provision of health care services at the doorsteps of the people complimented with
mass educational and motivational programme has not only provided dynamism to the
heath care programmes but also made possible the viable functioning of Anganwaries,
as well as nutrition supplement programme.
10
Despite concerted efforts by the programme planners, a recent study in
Haryana shows that the education of mother has the most striking relationship to
undernutrition as children of illiterate mothers are almost twice as likely to be
malnourished as children of mothers with at least a high school education
(NFHS,1993).
The abject poverty conditions, however, are the root cause of
illiteracy, undernutrition, and malnutrition. The Rapid survey results shows that
although, the educated women’s response have had reported variations in the
utilisation of health services. Yet, the dominant response not only underline the
demand for private services by educated families or the growing privileged class, but
also has shadowed the very existence of public sector health facilities in rural areas so
for as the role of basic health worker is concerned. Another study indicates that in
rural areas of Dungarpur district of Rajasthan education influences the perception of
illness and therefore expensive health care provider (private sector) is preferred for
the treatment of the sick member in the family (Sodani 1999). These trends in the
utilisation of rural health care services have serious policy implications.
11
REFERENCES
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2. WHO, 1976; New Trends and Approaches in the Delivery of Maternal and
child care in Health Services, World Health Organisation, Geneva
(Technical Report Series No 600).
3. Rapid Survey, 1997; Assessment of Coverage, Quality and Clint
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Population Research Centre, Panjab University, Chandigarh.
4. Rapid Survey, 1997; Assessment of Coverage, Quality and Clint
Satisfaction with FW services in Kaithal District, (Haryana), Population
Research Centre, Panjab University, Chandigarh.
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Research Centre, Panjab University, Chandigarh.
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Research Centre, Panjab University, Chandigarh.
7. Rapid Survey, 2000; Assessment of Coverage, and Clint Satisfaction and
Quality of Family Welfare Services in Faridabad District, (Haryana),
Population Research Centre, Panjab University, Chandigarh.
8. MHFW; 1996; Rural Health Statistics in India, Rural Health Division,
Directorate General of Health Services, Ministry of Health & Family
Welfare (GOI), Nirman Bhawan, December (bulletin).
9. NFHS; 1995; National Family Health Survey, (MCH and Family Planning)
Haryana,
Summary Report,
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10. P. R. Sodani, 1999; “Determinants of Demand for Health Care in the
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14