Lives lost to State Apathy

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One of the most backward regions in Jharkhand

Home to Santhals (ST) and Paharias (PTG )

More than 50% hills & forests

Subsistence farming

Hard to reach area

Malaria endemic

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Source: Pradan–UNICEF project 2011, NFHS 2005-06

Indicators Sundarpahari block Jharkhand

Body Mass Index below normal (< 18.5 kg/m2)

70% of pregnant women 42.45% (NFHS 2005-06)

Haemoglobin belownormal (11.5- 15g/dl)

78% of pregnant women have Hb between 7-9 g/dl

69.55% (NFHS 2005-06)

Underweight (0-3 years) children

56% underweight 21% severely underweight

54.6% underweight (NFHS 2005-06)

Mean weight gain during pregnancy (10 -12 kgsnormal)

3 kgs

Low birth weight babies 46%

Diet of rice and potato

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For a period of 1 year: April 2011 – March 2012

Covering 2 Blocks: Sundarpahari and parts of Poreyahat

Total population 1,26,659 – 48% scheduled tribes

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Tools used were [1]Primary Informer format and [2]Maternal death review format – prescribed by SRS

Firstly, all deaths of women in the age group of 15-49 years were tracked using tool [1] Filled by trained community volunteers e.g. ASHA

Within these maternal deaths were culled out Upto 42 days after birth Death related to Pregnancy Medical termination of pregnancy Not accidental

PRADAN staff with trained volunteers collected information at the household level using tool [2]

Interviews were conducted with family member present with the woman at the time of seeking care or closest relative with requisite information or neighbours 5

6

1

2

3

4

1

3 3

1

3

1 1

0

Recorded 23 dead women in 3150 births

At 730, MMR is 3 times the State figure of 278/1,00,000 live births (Annual Health Survey, 2011)

7

8

30%

17%22%

22%

9%

Eclampsia

Fever-Malaria ?

Heamorrhage

Others

Sepsis

Of the 23 cases only 3 children survived

Still birth

Unborn

Died

Survived

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Socio-economically weaker sections and vulnerable groups

74% from indigenous communities (Santhals)

85% do not have formal education

61% in 18-22 age group

43% had their first pregnancy0

2

4

6

8

10

12

14

16

18

ST OBC General

Demography of the maternal deaths

10

11

0 2 4 6 8 10 12 14 16 18

Deciding to seek care (of 23 cases)

Obtaining care (of 14 cases)

Reaching health facility (of 14 cases)

18

14

13

Indicators Percentage

No medical care 13%

First point of care local practitioners/quacks 65%

ANC – Tetanus injection only 43%

No prior information regarding own condition/birth planning

87%

Antepartum deaths 30%

Intrapartum deaths 22%

Postpartum deaths 48%

12

Point of care

13

4%

50%

4%

8%

13%

4%4% 13%

Government PHC Local practitioner Self

Family Midwife Private hospital

Government - CHC Government District hospital

0 2 4 6 8 10 12 14 16 18

Local practitioner/quacks

District hospital

Bihar FRU

Private hospital

Community Health Centre

Primary Health Centre

Bihar Community Health Centre

Bihar District hospital

14

8 out of 14 multiple referral cases15

0

1

2

3

4

5

6

7

8

9

10

District hospital Community Health Centre

Primary Health Centre

Total no. of cases referred

1. Blood transfusion

2. Complicated labour

As per Operational Guidelines on Maternal & Newborn Health 2010:

Community health centre – Basic emergency obstetric care

District hospital - comprehensive emergency obstetric care

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80% of the villages are relatively well connected by roads

Mean distance from functional (first) facility - 18 kms (shortest 1km to PHC, longest 40 kms to CHC)

Mean time taken to reach the nearest functional facility from home after appearance of symptoms - 7.5 hours

Mean time taken for referral between CHC to DH to Bhagalpur - 7 hours

Nearest functional FRU - Jawaharlal Nehru Medical College & Hospital-Bhagalpur (Bihar) - 70 km from District headquarters

48% deaths occurred at home, 35% at hospital and the rest in transit

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23 pregnant women

9 died at home

14 reached the 1st facility

3 returned home & died

3 died enroute 2nd facility

8 reached 2nd facility

4 died at the 2nd facility

3 died at 3rd facility

4 reached 3rd facility

1 reached & died at the 4th

facility

Facilities include private hospitals/clinics and government facilities - CHC, DH, FRU18

Facility In transit Return from facility Home

1 1

3

5

22 2

3

4

Intrapartum deaths Anterpartum deaths Postpartum deaths

19

Simaldhabvillage

Called private vehicle at 3

am, arrived at 9 am

Reached GoddaDistrict Hospital at

11 am

Jawaharlal Nehru Medical College & hospital, Bhagalpur

Died enroutearound 6 pm

30 kms

70 kms

Referred from Godda District

Hospital to FRU in Bhagalpur

Arranged private vehicle at 5pm

20

Mean out of pocket expenses –Rs 4478 (range 400-6,000)

0

1000

2000

3000

4000

5000

6000

1 2 3 4 5 6 7 8 9 10

Vehicle Quacks Pvt Clinic Govt. Facility

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Move to the verandah I have to close the ward---ANM to pregnant woman suffering convulsions at CHC

Do not step in my vehicle if you don’t have money---Driver of MamtaVahan to husband of pregnant woman

Why have you come here, nothing can be done, take the woman to Bhagalpur----Doctor to woman’s family arrived for delivery at District Hospital

Pay up! Throw the baby in the ditch and get lost---Nurse yelling at a woman who had a still birth

Then you call the person whom you gave money and let her do the delivery---ANM to family members asking them to pay her after they had paid Rs 300 to the ANM on duty before her

You illiterate woman, pay up else we will thrash you---Nurse to woman after she had a still birth

DIGNITY?!

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Accessible and functional FRU, EMOC

RESIDENT ANMs

COMPLETE ANC & PNC

FREE TREATMENT & DRUGS

ENTITLEMENTS

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Lost rights are never regained by appeals to the conscience of the usurpers, but by relentless struggle...

~ Ambedkar

7 Yrs of NRHM…and women continue to die

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