This post is part of a series of posts on cash transfers and maternal health. To read other posts in the series, click here. If CCTs are a part of your work or research, we’d love to hear from you. Contact us at clindahl@engenderhealth.org if you are interested in writing a guest post on the topic. The following post was originally published on Maternal Mortality Daily.
As we discussed maternal health in Seraikela with government officials and health providers, we found different views on the same story: Janani Suraksha Yojana (JSY) has led to a rapid increase in institutional delivery. The increase more or less follows the government’s plan for JSY – at least at this early stage. But, for as much as the government officials and health providers we talked to were eager to proclaim that this increase had led to major changes in Seriakela, when it came to the question of what would improve maternal health further, they had a lot of different ideas.
Government Officials
We discussed maternal health with three government officials who work in the district that Seriakela belongs to, including the Dr. Chauhan, the top government public health official in the district. When we asked him about JSY and whether it is being implemented effectively, he pointed to JSY as responsible for increasing institutional deliveries in the district from 0 to 30-40 percent of total deliveries. In response to one question about the quality of services available in the district, he said, “Of course, quality is automatically improved when women go to an institution. There is a skilled birth attendant, and she will have her tools and she will be part of a referral system.”
Another district health official boasted of the positive impact of JSY on institutional delivery, adding that, though there were initially some problems with delivery of JSY payments, the government had eliminated backlogs and the program was now moving smoothly. When it came to the question of what would improve maternal health in the district, he pointed to the district’s bad roads, inadequate space in Primary Health Centers. But, he also noted two potentially major issues as almost as asides. In the midst of a discussion of whether JSY was being implemented effectively, he said, matter-of-factly, “After the government warned doctors that they might not be paid, institutional delivery went up,” and that awareness of JSY remains uneven because “some sahiyas are more active than others.”
When we asked Dr. Chauhan, about what changes would make maternal health in the district improve more, he continued to emphasize the point that increasing institutional delivery was the most important thing. However, the means he suggested to increase institutional delivery were broader-reaching than JSY’s emphasis on building demand. When it came to discussing reasons why institutional delivery remains well below the 100 percent mark, the government official said “People want their deliveries in facilities. The problems are that they can’t get there, they are poor, and the facilities need to be strengthened. If you strengthen the facilities, they will come.” While Dr. Chauhan declared a need for further research to assess the needs of the facilities in his districts, he named some very specific issues. The district’s lone ambulance was, “Not exactly functional, not exactly not functional. Are you familiar with the term ‘gasping’?” and pointed to the need for village health sub-centers, which currently have neither the staff nor the equipment to provide skilled care at delivery to be better equipped: with electricity, running water and phone lines. Later, he declared, “The moment we improve transportation, have running water and electricity at health subcenters, and improve communication we will see more institutional deliveries. Give it three to six months after these improvements and we will be at 70 or 80% institutional deliveries.”
Health Workers
The health workers we talked to about what measures might improve maternal health had different views about what might improve maternal health in the district, both from each other, and from the government’s health officials.
Dr. Chattergee, an obstetrician we talked to at the main public hospital in Jamshedpur said that the “Biggest challenges to reducing maternal mortality are to educate women especially on health, nutrition and hygiene—and improving the health system.” As we followed him on rounds of the maternity ward – two rooms full of very quiet women, most waiting to deliver or had given birth within the last day or so – he asked a few about their nutritional status, pointing out that one was “very anaemic” and, saying of another, “her husband is a farmer, so she gets the balance of fruits and vegetables that she needs.” When we asked him later about who comes with women to the hospital, he listed sahiyas, women relatives and husbands – and, indeed, there were several women relatives and sahiyas in the ward, as well as older children; and perhaps twenty men milling around in the corridor outside of the ward. Dr. Chattergee told us that women sometimes arrive alone, or are accompanied by their husbands, who then leave them to face delivery and any procedures that go with it on their own. He proclaimed, “Women’s health is not only about women. It is about husbands too. To improve women’s health the husband must be held responsible.”
While Dr. Chattergee was emphatic about the role of decisions by women and their husbands in determining their health, he also pointed to a number of broader obstacles that may have an impact on the health of all of the patients in his hospital, including the women who he treats. Within the hospital, he gestured dismissively around him to the hospital structure as a problem, stemming from the much larger problem of mismanagement in the government. “There is no lack of funds. Funds are everywhere. But they are not utilized by genuine people,” he said of government health administrators. He continued to reiterate the importance of good leadership at all levels of the health system: “If the captain is alright and brave, then the soldiers can do accordingly.”
Much of our conversation with Rani, one of the three midwives staffing the primary health center, covered familiar ground: there was only one room and not enough beds for the increased number of women, leading them to have to send women home as little as eight hours after delivery, and leaving follow-up care to sahiyas. In contrast to Dr. Chauhan’s assurances that the primary health centers are generally equipped to care for women, Rani told us that there is rarely sufficient saline solution, and that women sometimes have to purchase the drugs they need on their own.
When we asked Rani about the biggest challenges that she finds in her work, she had little to say about roads or general infrastructure, or even about JSY. If one thing would help, she said, it would be to have either a doctor or a guard on duty at all times, since the ANMs are on duty 24 hours a day. Rani told us, “If a women goes into labour at night, she is often accompanied by a husband who is volatile, sometimes drunk and can be verbally abusive to us. They would not behave that way in front of a doctor—and the security guard would also help this situation.”
Rani and the other ANMs told us that in addition to the husbands, “In the villages, women deliver standing up, and sometimes they get upset when they want to deliver standing instead of lying down. They kick, they’re very stubborn.” When we asked them about what they do in this sort of situation, Rani said, “Sometimes we shout, sometimes we tell them ‘If you don’t calm down, we will operate.’” But, she continued, “After the baby is born, we all laugh together.”
Where to from here?
The issues that the health officials and Dr. Chattergee raised were hard to dispute: better roads would make a big difference; the hospital could certainly use some remodeling, and surely, a more engaged state health bureaucracy would make all sorts of changes easier to achieve. In talking to Rani and the other ANMs, I was really struck by how different their main concerns were, and how much those suggested about the state of health services and their relationship to the community. On one hand, surely, the ANMs should be able to do their jobs without having to worry about what a drunk, aggressive husband might do; while, on the other, how important is it that women who deliver in facilities have to lie down to deliver? Could some of the issues that have to do with husbands’ place in the situation – whether at the public hospital or at the primary health center might be difficult to change: “Holding husbands responsible,” as Dr. Chatterjee suggested is hardly simple.
On the whole, it seems that, while different officials and health workers have different ideas about what is needed to improve maternal health further, complex changes are needed. The question remains, however, whether policy will be responsive. Will focusing on efforts to generate demand for health services inspire improvements in health service quality? Or will political momentum continue to push policy toward building demand for services and/or using financial incentives to promote relatively simple changes?