One night in October, 22-year-old Nagina Khatoon went into labour. It was her first pregnancy. The next morning, the resident of Katikheda village in Uttar Pradesh’s Hapur district called Suman, the village’s Accredited Social Health Activist, or ASHA,.
Seeing Khatoon’s condition, Suman called the free ambulance service provided by the state, which arrived in 15 minutes. Khatoon’s husband and relatives accompanied her to the hospital where she delivered a healthy baby boy.
In Katikheda, many women still deliver their babies at home. The government wants more women to have safer deliveries in hospitals, and the free ambulance service is one incentive to get them there.
India has a high maternal mortality ratio. For every one lakh births in the country, 178 women die, according to sample registration system data from 2012-’13.
Uttar Pradesh’s maternal mortality ratio is higher than the national average at 258 maternal deaths for every one lakh births.
Nearly half the women in the state who die during childbirth do so giving birth in their homes. Another 13.8% of the deaths occur during transit from home to the health facility, or further, to a referral hospital.
In 2012, the Uttar Pradesh government launched a free ambulance service for all medical emergencies, from accidents to labour pains. An ambulance could be called by dialling the number 108.
Two years later, the government started another service that could be accessed by dialling 102. This service was exclusively for the treatment and care of pregnant women and infants. It has become popular with women opting for hospital deliveries.
While the 108 service picks and drops off a patient to a health facility, the 102 service also drops the women and children back home.
The Akhilesh Yadav government set up public-private partnerships used in 17 states and union territories to provide these free ambulance services.
The government signed agreements for the 108 and 102 ambulances with a non-profit organisation called GVK-EMRI, which is a collaboration of the GVK group and the Emergency Management and Research Institute. GVK-EMRI provides the ambulances, paramedic staff, drivers, and has built and handles a call centre to respond to emergency calls. The company has a fleet of 11,000 ambulances in the state.
Hapur has 16 ambulances for the 102 service and six ambulances for the 108 service.
The question is: how much does this free ambulance service help when the hospitals they drop patients off at lack basic facilities.
Home deliveries still preferred
Many women in Hapur use the ambulance service for their pregnancy check-ups, to get to hospital when they are in labour, and to take infants up to the age of one to hospital for check ups. If these women had to arrange transport themselves, especially at odd hours of the night, it could cost them up to Rs 1,000 – a substantial expense for them.
The two ambulance services in Hapur are called between 10 and 12 times each day, said Abhishek Shrivastav, the district coordinator for GVK-EMRI.
Data collected by the state’s National Health Mission shows that the percentage of institutional deliveries has been climbing steadily from 42.5% of the total estimated deliveries in 2013-’14 to 51.5% in 2015-’16. But it also shows that nearly half of childbearing women in the state are still having their babies at home.
Sushila is a field worker for the non-profit organisation Action India. Her job is to educate women in Hapur’s villages about reproductive health, and she sees many women trying to deliver their babies at home until it becomes necessary for them to go to hospital.
“We were conducting a survey where we asked pregnant women about their preferences at the time of delivery,” she said. “In one case, when I asked the pregnant woman, her mother-in-law interrupted and said that they would try at home first and then see what needs to be done.”
Women prefer home deliveries for various reasons. It could be because of a lack of trust in government facilities due to ill treatment there previously, or poor infrastructure, poverty or simply having to travel long distances from home.
Basic facilities lacking
So what happens to women who are not able to have vaginal deliveries? They are in a fix whether they choose to have their babies at home or head to hospitals. The government health facilities neither offer cesarean section deliveries for women who need it, nor blood transfusions for women who are anaemic.
Hapur district is a relatively new district. It was carved out of Ghaziabad district in 2011. It does not have a district hospital. There are three community health centres in the district, including the one in Hapur city.
Community health centres are the first referral hospitals for primary health centres in a block – an administrative sub-division – and provide basic services related to reproductive medicine, paediatrics and general medicine. A district hospital is a step up from the community health centres and serves all people in the district. The district hospital should be able to provide complex surgical services for childbirth and trauma cases, psychiatry, dialysis and have a blood bank.
Hapur is one of the four districts in Uttar Pradesh along with Shamli, Amethi and Shambhal that does not have a district government blood bank.
The absence of a blood bank means that government-run health centres in the district cannot offer full-fledged services for surgeries like C-sections. Before any surgery, a surgeon needs to keep a blood bag handy in case of complications even if it is not eventually used. While it is still possible to arrange for blood for a planned surgery, it is very difficult to do so during emergencies.
The need for blood banks is greater in Uttar Pradesh where more than 90% of women of reproductive age are anaemic and could need blood transfusions during childbirth.
“We only conduct natural deliveries,” said Dr Rajendra Gupta, the medical superintendent at the community health centre in Hapur block. ”Conducting a C-section surgery is a responsibility. We do not have round the clock anaesthetists and facilities for post-operative care.”
The two anaesthetists employed at the community health centre are available only for one shift between 8 am and 2 pm, said Gupta. The community health centre has conducted only seven C-section surgeries since April, and four in 2015 by using blood from nearby private blood bank.
The government data on the women who undergo C-sections in both government and private hospitals in the state shows that hospitals are performing too few C-section deliveries. The percentage of C-sections as against total live births in the state is rising slowly. It was a little more than 3% in 2015-’16.
But given the rate of complicated pregnancies in any population, the World Health Organisation’s estimates that the ideal rate of C-sections should be 10%-15% of all deliveries. Studies show that when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases.
A C-section delivery is recommended when a vaginal birth is too risky for the mother and foetus. For instance, when the mother has high blood pressure during pregnancy or if there is excessive vaginal bleeding.
“I think the community is underserved,” said Dr Neelam Singh, who runs the non-profit organisation Vatsalya in Lucknow that works towards providing health facilities for women and children. “Five percent of C-section is mandatory in a population. Lack of facilities and competencies may be contributing to high maternal mortality.”
Six months ago, the Hapur district hospital had applied to have a blood storage unit attached to Meerut’s Lala Lajpat Rai Medical College where it could store about 200 units of blood. However, the proposal ran into a road block with state health authorities wanting the laboratory technician in charge of the unit to be trained for another six months, said Gupta.
For all practical purposes, the community health centre has to rely on a the privately-run Dev Nandini Hospital, which has a registered blood bank. But by all accounts, the community health centre doctors rarely bother to call the private hospital for blood. Instead, when a pregnant woman in need of surgery and blood comes to the centre, she is sent further up the government health facility chain.
“We refer them to Meerut Medical College,” said Gupta. “The woman goes in the same ambulance that she came in.”
Is the scheme successful?
Meerut is a little more than half an hour away from Hapur city, and a good option for referral. The question is whether all women in need are actually referred to the Meerut facility.
On December 25, 23-year old Dolly from Goyna village went into labour. She used the ambulance service and delivered a baby boy at the community health centre and was kept under observation for 48 hours.
A day after giving birth, her face started swelling, and she experienced vomiting and severe dizziness. The doctors at the centre told her that she was severely anaemic and needed a blood transfusion immediately. She was told to go to a private facility.
“I was given two bottles of blood,” she said. Now, almost two months later, Dolly is not much better and her face is still reddish and swollen.
When government facilities fall short, patients’ out-of-pocket expenditure jumps significantly. In Dolly’s case, the family had to spend about Rs 35,000 at the private hospital where she was treated for her anaemia. Her husband, who works as a tailor in Delhi, could barely afford this.
Asked whether she was referred to a government hospital, Dolly said, “No.”
Shrivastav confirmed that the ambulance service has been seldom used for referral service in cases of pregnant women.
When 27-year-old Reena from Katikheda was pregnant with her third child in 2014, she used the 102 ambulance service to reach the community health centre.
“I was in labour for nearly nine hours but was not able to deliver the baby,” she said. The government doctors had assured her of a natural delivery, but when the complications mounted at night, they asked her to go to a private hospital.
“Kaha baccha nahi bachega [The said the child will not survive otherwise],” she said.
Reena was not referred to a government hospital. She underwent a C-section in a private nursing home.
The government ambulance service cannot be used to transport a woman to a private facility.
When she was pregnant again last year, she decided to go straight to a private hospital.
“I did not want to take a chance,” she said, ready to pay the Rs 40,000 that she had to fork out for each of her deliveries.
Khatoon, who delivered her baby safely in October, claimed that she was not given any food during her stay in the community health centre. After two days, she was not allowed to take her child back home in the ambulance.
The reason? Suman, her Accredited Social Health Activist, had dialled 108 instead of 102.
This reporting project has been made possible partly by funding from New Venture Fund for Communications.