Lachava, a landless agricultural worker, sat on the floor outside the maternity ward of the Mother and Child Health Centre in Karimnagar, Telangana, where her daughter had given birth to a baby girl. Open in front of her was a green bag – a KCR Kit, named after the Telangana Chief Minister K Chandrashekar Rao and which has become the most visible symbol of maternal health reforms in the state.
Lachava put away the soaps, oil, talcum powder and mosquito net, and took out a soft blanket from the bag in which to wrap the baby.
“We don’t need to buy anything for the baby,” she said. “We are poor people and this helps us a lot.”
The kit is equipped with 16 essential items for a mother and her newborn. The KCR Kit scheme also a cash component of Rs 13,000 for the birth of a girl and Rs 12,000 for the birth of a boy. The money is transferred directly to beneficiary bank accounts in four instalments, starting from a pregnant woman’s first antenatal check check up. The last instalment is paid after the child’s second-round immunisation. All pregnant women in Telangana are eligible for the scheme.
Since it was launched in June 2017, the KCR Kit scheme has had close to four lakh beneficiaries. The scheme has contributed to Telangana’s rare success in improving the number of deliveries in public hospitals by improving the quality of maternal health services.
Acting on indicators
Telangana has been under pressure to act on maternal mortality ever since the last National Family Health Survey in 2014-’15 was released,. The survey showed that even though institutional deliveries in the state were among the highest in the country at 92%, most births took place in private hospitals and only about 30% of births took place in public facilities. More alarmingly, the rate of caesarean sections in Telangana – 74.5% in the private sector and 40.3% in the public sector – was the highest in the country. Experts correlated the high caesarean sections with more women giving birth in private hospitals.
Data from the Sample Registration System indicates Telangana’s maternal mortality ratio or MMR dropped from 92 per 1,00,000 live births in 2011-’13 to 81 per 1,00,000 live births in 2014-’16. The United Nations’ Sustainable Development Goal for maternal mortality is still lower at 70 per 1,00,000 live births.
In 2017, Telangana undertook a wide range of reforms towards the dual goals of reducing the number of Caesarean sections and reducing maternal mortality. Since the implementation of these reforms, the state government says that public institutional deliveries have risen from just over 30% to nearly 50%.
For the period between 2018-’19, of the total number of deliveries in Telangana, 2,22,588 took place in government hospitals and 1,57,690 took place in private, according to government data.
“With almost 70% deliveries in private facilities, there was a huge financial burden for the poor people. We had to address that and regulate the high C-section rates,” said Karuna Vakati, who was commissioner for health and family welfare from October 2016 to September 2018 and is currently commissioner for land administration. Vakati is a a no-nonsense bureaucrat, who is widely credited for pulling off health reforms.
“My first priority was to bring women into public health care facilities,” she said.
The 150-bed Mother and Child Health Centre in Karimnagar, which handles close to 800 deliveries every month, opened in 2017. It was built as part of the infrastructural upgrade of maternal health facilities in Telangana, which was one of the first to adopt the guidelines for the standardisation of labour rooms that were released in 2016 by the Ministry of Health and Family Welfare.
“When we started, we found we were nowhere near the guidelines and the condition of labour rooms was really quite bad,” said Dr Radha Reddy, who worked on the project as a consultant with UNICEF India. Now, almost 300 labour rooms across the state have upgraded and standardised.
A new cadre of midwives
In 2017, Telangana launched midwifery-led care in public health facilities, in partnership with Fernandez Hospital, a private hospital in Hyderabad and one of the few that offers midwifery care. A batch of 30 nurses is being trained over a period of 18 months to create a special cadre of midwives who can provide quality care during pregnancy and childbirth and prevent maternal and infant deaths.
Despite decades of advocacy from international institutions, India has dragged its feet in introducing specialised midwifery for the dedicated care of pregnant women and newborns. India has Auxillary Nurse Midwives or ANMs and Registered Nurse and Registered Midwives or RNRMs as recognised by the Indian Nursing Council. But these health workers get only a few months of midwifery training along with other nursing training.
Telangana’s midwifery programme had now become a model for a national midwifery initiative. In December 2018, the Government of India announced the introduction of midwifery in public health. A cadre of Nurse Practitioners in Midwifery will be created, members of which will be skilled according to standards set by the International Confederation of Midwives.
The midwifery course in Telangana was started in Karimnagar, which has among the highest rates of C-sections in the state. Chandra Leela, an ANM in the district for the last 28 years, said that most women in the area would have babies after “an operation”, but for the last two years she has been tasked with promoting natural birth.
Dr Manjula Anandala, a gynaecologist at the Mother and Child Health Centre in Karimnagar, had little idea about midwifery until the course was started, “We have a shortage of doctors and nurses and the presence of midwives made a big difference,” she said. “The midwives share our workload and they also provide patient and respectful care to the mothers, which we cannot, as we simply don’t have the time.”
Apart from promoting safer childbirth, midwives can address the lack of availability of skilled personnel in remote areas. “It was very clear that we were not going to get enough doctors, so the next option was that we invest in paramedical workers who are already present in those areas and build up their skills in a manner in which they would be able to provide safe deliveries and leave the complicated cases to the doctors,” said Vakati.
Another crucial part of Telangana’s maternal health reforms is the introduction of an ambulance service or the Amma Vodi programme to help women in tribal and remote areas who go into labour to get to a health facility in time. The programme offers a free pickup and drop for pregnant women going for antenatal checkups, deliveries and immunisation. The programme is backed by a call centre that provides 24-hour service on a toll-free number.
Alongside this, data entry operators were employed at health centres to build an online system that connects various health institutions. “We have the information and graphs, so that lends itself to a lot of analytics. If there is a low birth weight for instance, what area is it from?” said Vakati.
Ultimately, Telangana’s maternal health reforms might be working simply by making access to public health facilities less intimidating.
“The whole idea is to make the mothers feel welcome,” said Vakati.
This reporting was supported by a grant from the European Journalism Centre, with funding from the Bill & Melinda Gates Foundation.