Eight months after Health Minister JP Nadda unveiled the Pradhan Mantri Surakshit Matritva Abhiyan that includes free antenatal care, pregnant women are still struggling to pay for a basic test – the ultrasound.

One such woman is Rekha Bhosale of Loni Kalbhor, a village on the outskirts of Pune city in Maharashtra. Twenty two-year-old Bhosale delivered her first child on Saturday. During her pregnancy, she attended antenatal care camps at the village primary health centre organised by health authorities as mandated by the new antenatal care scheme. She got all her other checks done at these camps, but had to have all four recommended ultrasounds performed at a private medical centre at the village after being referred there by government health officials. The Loni Kalbhor primary health centre does not have an ultrasound machine.

“We don’t have a choice but to refer [patients to private medical centres],” said Jalinder Salunkhe, aarogya sevak at the primary health centre at Loni Kalbhor. “There is a long queue at government hospitals where no one wants to go.”

An ultrasound, also called a sonography, is an essential medical imaging technique used to track the development and detect anomalies in a foetus. While, the World Health Organisation recommends at least one ultrasound before 24 weeks of gestation to detect “foetal anomalies and multiple pregnancies”, India’s National Health Portal recommends at least four sonographies at different times during pregnancy to catch possible complications.

Deputy commissioner for maternal health with the union ministry of health Dr Dinesh Baswal, who is also in charge of this antenatal care programme at the national level, said that the purpose of the programme was to ensure that high-risk pregnancies are picked up early. Blood and urine tests offered free of cost at the primary health centre help detect other medical conditions such as gestational diabetes, a complication which can prove risky for both mother and child.

“If we identify the high-risk pregnancies, we can reduce the maternal deaths which are higher in women who suffer from diabetes, hypertension and other medical conditions during pregnancy,” said Baswal.

Dr Vaibhav Dangad, senior gynaecologist who runs a private hospital in the area and attends to patients at the Loni Kalbhor antenatal care camps, said: “Sonography is a life-saving test for pregnant women. Only a sonography will tell us the position of the placenta, which is important to know when conducting a delivery. If we don’t conduct ultrasounds, we will not know if the foetus is in any distress, which is vital to avoid stillbirths.”

Bhosale spent nearly Rs 4,500 on the tests. Bhosale’s husband said that he did not earn enough and had to borrow money to pay for the tests.

Rekha Bhosale, who has just had her first child and paid Rs 4,500 for ultrasound tests that are supposed to be free. (Photo: Priyanka Vora)

Women like Bhosale who come from low-income families are often at a greater risks during their pregnancy because of poor access to nutrition and general healthcare. In 2015, India recorded 174 deaths per 100,000 live births faring a little better than Pakistan which recorded a maternal mortality rate of 178. According to UNICEF, women from the poorest backgrounds have about a mortality rate that is two and a half times higher than this average.

The same women who are prone to high-risk pregnancies are now paying large amounts to get their ultrasound tests. Twenty two-year old Seema Kombre, who recently delivered her third child at the Loni Kalbhor primary health centre, said that her husband had been reluctant to pay for her sonographies. “My father paid for all the three sonography procedures,” she said. Her father, a sugarcane farmer tapped into his savings to pay for her daughter’s test.

Health activists point out that the money that these women spend on ultrasound tests can be put to better use. “Nearly half of the women in India are anemic,” said Smriti Acharya, a programme director of SNEHA, a non-profit working for improving maternal and child health in Maharashtra. “The money which these women can use to buy food is being diverted towards paying for such tests. Most of the women come from slums, they take personal loans to pay for their childbirth-related costs.”

No machines or no doctors

State governments are supposed to organise camps for free antenatal check ups on the 9th of every month. A doctor from the private sector, preferably a gynaecologist, and the government medical officer are supposed to conduct checkups and perform test, the results of which are to be provided to patients on the same day. The health ministry’s also says that “services including ultrasound, blood and urine tests will be provided in addition to the routine antenatal check-ups at the identified health facility/outreach in both rural and urban areas.”

Pune district has only nine government-run ultrasound centres among its 25 rural hospitals. Ideally, every rural hospital should have one ultrasound machine.

Loni Kalbhor has one of the better equipped primary health centres in Maharashtra. In the past three years, Jadhav said that the primary health centre received medical equipment worth Rs 20 lakh from well-wishers. The primary health centre is popular for having the highest number of childbirths. However, it does not have an ultrasound machine.

Delivery room at the Loni Kalbhor primary health centre. (Photo: Priyanka Vora)

The antenatal care programme has a provision that the government centres can enter public private partnerships with private hospitals to provide free or subsidised ultrasounds. But, the Loni Kalbhor primary health centre is still scouting for a private centre to conduct sonographies even at subsidised rates.

Officials at the Loni Kalbhor primary health center have observed that many pregnant women miss their ultrasound tests simply because of the costs involved.

“There are pregnant women, especially migrants who don’t get any ultrasounds,” said medical officer Dr DJ Jadhav. “We can’t conduct a even a normal delivery without doing an ultrasound.”

Jadhav said that some private centres perform free ultrasounds because of goodwill towards government health officials. Dangad is willing to donate his sonography machine for such procedures but said that there was no doctor to run the time-consuming imaging test.

Health activist Kajal Jain with the Jan Arogya Abhiyan has closely studied the problem of poor access to ultrasounds. “There are machines which are lying dysfunctional,” said Jain. “In one of the district hospitals in Pune, the machine is lying unused since 2008.”

The Jan Arogya Abhiyan has conducted a study and found that only one of 18 rural hospitals across 12 districts of Maharashtra has a functional ultrasound machine. “In some places, the machine was not working and in others there was no doctor to operate the machine,” said Jain.

Jain complained that several private doctors have been exploiting the shortage of ultrasound machines in government facilities. “Doctors who were earlier charging Rs 600 are now charging Rs 1,000 for the same ultrasound,” she alleged. “Despite so many government schemes for maternal health, women are spending money on such tests.”

This reporting project has been made possible partly by funding from New Venture Fund for Communications.