New tools to combat Maternal Mortality in Bihar
By Aditya Malaviya
Bihar, March 2009 : 24-year old Neela Devi was due for her first delivery. Her husband, Bhushan Kumar, a 28-year old labourer working at a construction site in Delhi as a manual labourer, could not come home to be with her because of the prohibitive cost of travel. Understandable, given that he earned about Rs 4000 in a good month, barely enough to support two households - one in Delhi and the other in Majhauli. The responsibility of looking after his pregnant wife now lay with his younger brother and sister-in-law, who also lived in the same village.
At 1 am in the morning of 17th May, 2008, Neelam complained of labour pain. Her brother and sister-in-law took her in a rickshaw to the Bidupur Primary Health Centre (PHC), six kilometers away. The village Accredited Social Health Activist (ASHA) worker, Chandrakala Devi, was called to the PHC, which she reached on her husband’s bicycle.
Maternal and Perinatal Death Inquiry and Response (MAPEDIR) is a tool to thoroughly examine and respond to the social, biological and medical events that lead to maternal or perinatal death.
“I reached the PHC at 1 am in the morning. The ANM examined her even as she lay on the floor. No other medical care was provided, and Neelam and her family were left to fend for themselves,says Chandrakala.
At 3 am in the morning, Neelam was again examined by the ANM and was referred to Hajipur, as the family was told that the baby was larger than normal, and hence she may need to go in for a caesarian delivery”.
After spending 15 hours at the PHC in pain and discomfort, with the family helplessly looking on, Neelam was finally taken to Hajipur in an ambulance at 4 pm in the evening. Says 75-year old Basmatia Kunwar, a neigbbour who was with Neelam Devi at the PHC: “We asked the ambulance driver to take Neelam to Hajipur, but he refused to take us for only Rs 300 and demanded Rs. 500. Finally, we settled on Rs. 300 because we simply had no more money”. The journey to Hajipur was slow and painful, and especially so for Neelam due to her own medical condition, which was aggravated by the very bad road condition.
When Neelam arrived at the private clinic of an obstetrician in Hajipur, the doctor was not available. She was then rushed to the Sadar Hospital. By then she had already begun to bleed heavily and Chandrakala tried to stem the bleeding by putting a cotton packing, but to little avail. Neelam went into labour and gave birth to a girl child while in the emergency ward. Soon, her condition began to deteriorate, and she breathed her last around 8 pm in the night. Her newborn child was left crying for her mother.
“After the case came to light, I approached the family and explained the reason why we were doing the MAPEDIR interviews. We told the family that though they had suffered an irreparable loss, their help in understanding the circumstances leading to the unfortunate death of Neelam will help prevent innumerable such tragedies in the village. That clinched the issue for us, and we have encountered no resistance from either the family or the community thereafter”. Says Sunil Kumar Singh, Area Supervisor and an interviewer with MAPEDIR
“Decentralised planning under the National Rural Health Mission provides an opportunity for making programmes more responsive to local realities. However, this requires that the ground realities are adequately captured and fed back to communities and the health system for planning appropriate actions. Through Maternal and Perinatal Death Inquiry and Response (MAPEDIR), UNICEF has systematically captured ground realities of maternal deaths and use the evidence to generate community and program action. ” Says Bijaya Rajbhandari, State Representative, UNICEF Office for Bihar, Patna.
Inquiries are conducted for the deaths that occur in a community to identify common factors that can be acted upon to prevent further deaths. Ongoing inquiries over several years allow a community to assess the impact of its preventive actions and the need for additional interventions. There is also a need for a review of care provided to women and children and the health facilities that are in place where many deaths occur, to identify medical practices that need to be improved to prevent additional deaths.
UNICEF is supporting the pilot of this intervention in the district of Vaishali in Bihar, and intends to upscale it further in 2009.