HEALTH CARE

Making change possible

The United Nations Children's Fund's intervention in West Bengal's Purulia district has shown encouraging results in checking the incidence of maternal and child mortality. The agency has documented its initiative through photographs highlighting some aspects of the problem and measures taken to prevent them.

PHOTOGRAPHS BY ANITA KHEMKA

Ganga Mahato fetches water. A pregnant woman, she walks to the water pump and back eight to ten times a day. Adequate diet and proper rest is essential for all pregnant women to gain optimum weight and to give birth to a healthy child of normal birth weight. Women can carry on with light work during pregnancy but heavy work, like carrying weight, should be avoided.

THE United Nations Children's Fund's (UNICEF) support for reproductive and child health in West Bengals's Purulia district has led to encouraging results. In 2002, a UNICEF-sponsored study, "Availability and use of emergency and obstetric care services in four districts in West Bengal", by R.G. Kar Medical College, Kolkata, showed that emergency obstetric care (EmOC) was woefully inadequate in Purulia district, with disastrous consequences. It was accessed only by 27.7 per cent of pregnant women with complications, leading to high incidence of maternal death. Private health care facilities were also almost absent in the district. Of all institutional deliveries, only 4 per cent occurred in private facilities, where caesarean sections were done only in 16.6 per cent of cases.

According to the study, of all obstetric complications in the government facility the incidence of eclampsia (pregnancy-induced hypertension with convulsions) was highest, causing 54.7 per cent of all maternal deaths; out of every 100 pregnant women with eclampsia, 19 died.

Three days before delivering a boy, Mithu Roy goes with her husband to the Block Primary Health Centre 5 km away from their village. The problem of access to health care facilities often leads to maternal death in case of complications.

The study, which showed Purulia to be one of the districts with poor obstetric care facilities in West Bengal, led UNICEF to select the district for its intervention, with the active support of the State government.

UNICEF first started supporting the training of doctors and nurses on the management of eclampsia. This reduced the mortality of women suffering from eclampsia in the government hospitals from 19 per cent in 2002 to 8 per cent. Eclampsia now contributes to 30 per cent (54.7 per cent in 2002) of all maternal deaths in government clinics in the district. The new regimen for drug management - using magnesium sulphate - to treat eclampsia is now followed in all government clinics, reducing maternal mortality considerably.

Upashi Kisku bathes in a pond during her sixth pregnancy. Pond water in rural areas is used for bathing, cleaning after defecation, washing clothes and utensils and even cooking and drinking. Bathing in the pond during pregnancy and the post-partum period often leads to infections of the genito-urinary tract.

Besides treating eclampsia, UNICEF launched programmes to deal with the major causes of maternal mortality - haemorrhage; infection; disorders related to high blood pressure (hypertensive disorders, eclampsia); obstructed labour (labour that goes on more than 12 hours); and anaemia - and the ways of dealing with them such as focussed antenatal care, birth preparedness and complication readiness, skilled attendance at birth, post-partum and neonatal essential care within the first 24 hours and the first seven days of delivery, and access to emergency obstetric care.

UNICEF's "outreach mobility" support provided to auxiliary nurse midwives (ANMs) has resulted in the efficient and effective functioning of sub-centre clinics. It has also strengthened the outreach programme for reproductive and child health (RCH).

Urmilla Murmu in the eclampsia room at the Purulia District Hospital. She was initially admitted to the rural hospital with high fever and vomiting and was subsequently referred to the district hospital. Eclampsia is rarely seen in pregnant women with good antenatal care in urban areas but is common in backward districts.

To improve the quality of care in RCH, weighing scales, blood pressure instruments, stethoscopes, auto-disposable syringes, disposable delivery kits and other essential equipment have been supplied to the sub-centres. This has improved the quality of immunisation, antenatal and delivery care. Maternal and neonatal registers had been supplied to all sub-centres to improve record-keeping of maternal and neonatal care services, an important but neglected aspect in planning programmes.

To reach the community with better maternal and newborn care services, 424 dais (traditional midwives) have been trained in all blocks of the district and supplied with disposable delivery kits. Their training essentially focussed on their role as a link between families and the formal health system. This training aimed at increasing institutional deliveries and early identification of danger signs and appropriate referrals, apart from conducting clean deliveries, providing essential newborn care and ensuring antenatal and postnatal care. Dais from the Sabar and Birhor tribal communities were also trained. Birth preparedness and readiness to deal with complications were included in all training programmes. Monetary incentives were given to them and the mothers.

Bhadu Rajwar, 23, being delivered of her eighth child at home. The delivery was assisted by neighbours. The umbilical cord was not cut for more than an hour. In the absence of a midwife, the placenta may remain inside the mother's body and lead to post-partum haemorrhage.

Institutional deliveries increased in the district as a result of this training.

To improve newborn care, a 10-bed unit was constructed in the Purulia district hospital. This houses an air-conditioning unit, a central oxygen supply plant, a laundry unit, a nursing station and other cost-effective and efficient equipment, including an infusion pump, blood gas analyser, radiant warmer, phototherapy unit, newborn resuscitation set and so on. The provision of the much-needed equipment, oxygen and drugs in the district hospital with support from the district Panchayat and the district magistrate has equipped the hospital sufficiently to ensure an increase in child survival rates in the area. This facility, jointly supported by the Department of Health and Family Welfare, the Zilla Parishad, UNICEF and a non-governmental organisation, is also being linked to sub-divisional and rural hospitals, and block primary health centres across the district.

Alpana Mahato's baby, which has been delivered at home by a Trained Birth Assistant (TBA). Pregnant women in Purulia district are usually provided by UNICEF with a Disposable Delivery Kit, which contains a sterile blade for cutting the umbilical cord, a gauze piece, thread for tying the cord, and a plastic sheet for the mother to lie down on during delivery. Though delivery is safer in the presence of a TBA than in the absence of one, it is still fraught with risks.

The newborn unit at the district hospital, which is managed by two paediatricians and five nurses, is also in the process of training a new cadre of "newborn aides", who have passed standard X, to support the nursing staff.

The results of this experiment, monitored in the last seven months, are encouraging. For example, there is a reduction in the mortality of sick neonates from 50 per cent to 20 per cent; a 10 per cent rise in the number deliveries in the hospital; and 10 per cent increase in neonatal admissions. It is estimated that on an average the 10-bed unit can save some 104 neonates every year.

A baby delivered at home being weighed by a TBA using a Salter scale supplied by UNICEF. Newborn babies with low birth weight (less than 2,500 gm) need extra care such as more warmth, more frequent feeding, and protection from infection.

To improve the quality and coverage of EmOC, State- and district-level training workshops have been organised to impart knowledge on standards and guidelines. Ten master trainers from West Bengal were trained in EmOC at the Christian Medical College, Vellore. They, in turn, are training others. Charts and booklets on standard management practices on emergency obstetric and newborn care have been printed and distributed across the district.

Bindu Modi with her newborn twins. She had anaemia, oedema and pre-eclamptic toxaemia, and was referred from the Block Primary Health Centre to the district hospital. But she chose to go home. Though the delivery took place at the BPHC, hers was a complicated case and she suffered post-partum haemorrhage. Advice for referrals often goes unheeded.

The district and block-level medical officers (27) and nurses (35) who were given a short training course in EmOC in 2002 and 2003 have shown positive changes in management practices of obstetric complications, especially with respect to the management of eclampsia. This has led to an appreciable reduction in the number of deaths from eclampsia in the district hospital - by 11.6 percentage points from 2002 to 2004.

A premature baby, born grossly asphyxiated seven weeks before the expected date of delivery, in the New Born Care Unit. Birth asphyxia is the leading cause of neonatal deaths, after sepsis. It may occur as a result of difficult and prolonged labour and delivery attended by untrained or unskilled personnel. Unless immediate attention is given to the newborn, there is a chance of death or permanent brain damage.

Important RCH indicators are monitored in the district. This helps in detecting bottlenecks at different levels, planning for corrective actions, improving supervisory skills and enhancing record keeping.

A nurse teaches a mother how to breastfeed a newborn. Though it is a very natural phenomenon, new mothers should be taught how to breastfeed. Often lactation failure occurs owing to incorrect feeding techniques, which can harm the infant and consequently prove to be fatal for the infant.

Commenting on the Purulia experience, Cecilio Adorna, UNICEF's representative in India, said: "The Purulia district hospital interventions for saving maternal and newborn lives clearly shows us that with commitment and care coupled with appropriate technical support, a lot can be achieved at the grassroots level. Governments, NGOs and support agency partnerships have the solution here and now to make a dramatic improvement in maternal and child survival in India."

Integrated skill training on reproductive and child health for auxiliary nurse midwives in progress at the Purulia District Hospital. ANMs, health functionaries at the grassroots level, are posted at sub-centres. They are responsible for providing primary health care to the population and most of their activities are related to maternal and child health. Inservice training on reproductive and child health is provided to them for honing their skills in maternal care, newborn care, immunisation and contraceptive care.

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