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 1. IIPA, 1971; Family Planning Policy and Administration, Indian Institute of Public Administration, Indraprastha Estate, New Delhi, August 16-17 (Seminar Report Volume II) 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 Satisfaction with FW services in Kurukshetra District, (Haryana), 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. 5. Rapid Survey, 1999; Assessment of Coverage, Quality and Clint Satisfaction with FW services in Rohtak District, (Haryana), Population Research Centre, Panjab University, Chandigarh. 6. Rapid Survey, 2000; Assessment of Coverage, Quality and Clint Satisfaction with FW services in Jind District, (Haryana), Population 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, 12 Population Research Centre, Punjab University, Chandigarh. International Institute for Population Sciences, Bombay, February 1993. 10. P. R. Sodani, 1999; “Determinants of Demand for Health Care in the Surveyed Tribal Households of Selected Three Districts of Rajasthan”, Demography India, Vol 28. No 2 pp 257-271. 11. NFHS, 2001; Promoting Institutional Deliveries in Rural India: The Role of Antenatal-Care Services, National Family Health Survey Subject Reports Number 20 December. International Institute for Population sciences, Mumbai. 13 14
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