Social Autopsies of Maternal Deaths in Select Areas of Gujarat A Report by Jan Swasthya Abhiyan, Gujarat and CommonHealth

August 21, 2014

ACKNOWLEDGEMENTS

Our salutations to the women who lost their lives in child birth – may we all learn from their

sacrifice. Thanks to the families who spoke to us about their trials, despite their loss and grief.

Inputs provided by:

ANANDI, Dahod, Panchmahals – Pradeepa Dube, Rita Parmar, Urmila Baria

Tribhuvandas Foundation, Anand – Neha

SEWA Rural, Jhagadiya – Shobha Shah, Ranjanben

CHETNA RRC, Ahmedabad – Smita Bajpai, Arpita Suthar

Report compiled by:

Sunanda Ganju, Renu Khanna, Mahima Taparia, Pallavi Saha (SAHAJ), Vadodara

Case stories translated by – Mansi Shah, Parul Mistry and Seema Purohit

Report reviewed by:

Neeta Hardikar - ANANDI

Smita Bajpai - CHETNA RRC

Pankaj Shah, Shobha Shah - SEWA Rural

Gayatri Giri - CommonHealth

Alka Barua - CommonHealth

Dr. Lata Shah

Guidance from Subha Sri B and Sundari Ravindran (CommonHealth) are warmly acknowledged.

This report is a subset of a larger report cited as follows:

Subha Sri, B., & Khanna, R. (2014). Dead Women Talking - Learning from women’s experiences: A civil society report

on maternal deaths in India. CommonHealth and Jan Swasthya Abhiyan, 2014.

Contents ACKNOWLEDGEMENTS ....................................................................................................................... 2

1. Introduction ................................................................................................................................ 4

2. Objectives.................................................................................................................................... 7

3. Methodology ............................................................................................................................... 7

Limitations....................................................................................................................................... 9

4. Findings ..................................................................................................................................... 10

4.1 Profile of the women who died .............................................................................................. 11

4.2 Details of Deaths ............................................................................................................... 12

5. Issues emerging ............................................................................................................................. 15

5.1 Vulnerability of women – high risk assessment? .................................................................... 15

5.2 Poor quality of care in community based services - Absent or inadequate antenatal care ... 16

5.3. Poor quality of care – Absence of Post Partum Care ............................................................. 19

5.4 Referrals and Transport .......................................................................................................... 22

5.5 Out of Pocket Expenses........................................................................................................... 25

5.6 Lack of support/ facilities for arranging Blood ........................................................................ 27

5.7 Role of Public Health Facilities ................................................................................................ 28

6. Conclusion and Recommendations........................................................................................... 30

Annexure 1 Compilation of 46 Maternal Deaths in Gujarat

Annexure 2 Profile Tables of Women who died

Annexure 3 Stories of some women who died – English and Gujarati

1. Introduction

India has been reporting a steady decline in the country's maternal mortality ratio (MMR)

over the last few years. According to the latest reports, the MMR has fallen from 254 per 1,

00,000 live births in 2004-06 to 212 in 2007-09 to the latest figures of 178 per 1, 00,000 live

births in 2010-12 (1). However, this is far behind the Millennium Development Goal (MDG) 5

target of 109 per 1, 00,000 live births by 2015. It is now fairly certain that India will fail to

meet MDG 5.

Since the last decade, and especially since the launch of the National Rural Health Mission

(NRHM) in 2005, the Government of India has put in significant efforts to improve the

maternal health situation in the country. The primary focus of these initiatives has been to

promote institutional deliveries. The Janani Suraksha Yojana that provides conditional cash

entitlement to women to deliver in health facilities, and the more recent Janani Shishu

Suraksha Karyakram, are programmes to this end. In addition, the NRHM has also put in

significant efforts to strengthen health systems. However, civil society networks like

CommonHealth and Jan Swasthya Abhiyan have been expressing concern over this exclusive

push for institutional births and have suggested that the maternal health policy should

move away from the paradigm of institutional deliveries to that of safe deliveries.

While maternal health is much more than maternal deaths, maternal mortality ratio (MMR)

is well accepted as an indicator of a country’s maternal health status. In addition to

calculating aggregated MMR figures, several efforts have been made in the last few years to

analyse causes and contributors behind individual maternal deaths and use learning from

this exercise to improve health systems. The World Health Organization has published

guidelines for verbal autopsy of maternal deaths and this has been used in several countries

across the globe.

1 Registrar General of India, Ministry of Home Affairs (SRS Estimates 2013)

The GOI efforts on institutionalizing Maternal Death Reviews (MDR) have faced significant

challenges. By the government’s own admission (2) , as of March 2012, only 18% of all

expected maternal deaths were being reported and of these, only 2/3rd were being

reviewed by the district level committee for MDR. Also, this exercise was largely restricted

to finding a medical cause for death rather than identifying gaps in the health system and

instituting corrective action, the original objective of the whole process.

In additional to the above, one of the major shortcomings of the GOI instituted MDR review

process is of non availability of information in public domain. This lack of transparency in the

process precludes any engagement from other stakeholders like civil society, academics,

and professional associations in the process and signals a major lack of accountability.

Gujarat is among the four states in India which are close to achieving the Millennium

Development Goal 5. The Maternal Mortality Ratio is estimated at 122 per 100,000 live

births (SRS 2013) which has decreased by 26 points from 148 in 2007-09. However,

improvement in the nutritional status of women continues to be a challenge with every

second adolescent and more than half of the women in reproductive age group suffering

from anaemia. Pregnancy anaemia is almost universal (3).

Besides implementation of national programmes such as the National Rural Health Mission

and schemes such as the Janani Shishu Suraksha Yojana and Janani Suraksha Yojana,

others like Chiranjeevi Yojna, Kasturba Poshan Sahay Yojana, Indira Gandhi Matrutva Sahay

Jojana, Balsakha Yojana, 108 Free Ambulance, etc are some key interventions to bring

about an improvement in the health status of women and children in the state. These

efforts are welcome and indicative of the state’s attention for maternal and infant mortality

reduction. However, translating these efforts in to action has given rise to several concerns.

Studies point out that coordination among different maternal health interventions at

different levels is a weakness in Gujarat and point to a need for an improvement in capacity

to implement maternal health policy (4). Inequities persist in utilisation of maternal health

2 Maternal Death Review – Country Perspective, presentation by Dr Manisha Malhotra, Dy Commissioner,

Maternal Health, MoHFW, WHO multi-country workshop, Bangkok, Sep 2012 3 District Level Household Survey on Reproductive and Child Health, 2002- 2004

4 Sanneving, Linda, Asli Kulane, Aditi Iyer and Bengt Ahgren. Health system capacity: maternal health policy

implementation in the state of Gujarat, India. Global Health Action 2013, 6: 19629 http://dx.doi.org/10.3402/gha.v6i0.19629

care services – Saxena et al analysed DLHS data and found that three ANC visits, institutional

deliveries and use of modern contraceptives were significantly associated with caste group,

education and wealth. Being poor irrespective of caste group and place of residence is a

single most important factor in lower utilisation of maternal health care services (5).

As per April 2011-March 2012 data (6), maternal death reviews have been done and used for

strengthening the system. Out of 14,14,000 pregnancies per year, 12,86,000 deliveries occur

and an estimated 1900 maternal deaths per year (5-6 maternal deaths per day) and 38,500

Neonatal deaths (106 neonatal deaths every day) take place every year. According to the

same report, all 26 District Collectors and CDHOs are reviewing all the maternal deaths. This

has resulted in series of corrective actions to avert maternal deaths. The presentation states

that the following are being done:

Special 4 wheel drive vehicles launched to reach out to geographically difficult

terrains (12 vehicles in five districts).

Inter-Facility Transfer (IFT) services launched to address referral services from one

hospital to another further reducing transportation delays.

Essential drugs required for delivery and management of its complications made

available in facilities conducting delivery

Districts were sensitized and directed to implement use of partograph.

Technical Series for capacity building initiated on Acute Management of Third Stage

of Labor (AMTSL), Use of Partograph and Use of Magnesium Sulphate.

Pool of 30 MDR resource persons created at State level.

Newer approaches to help to understand why women die: Confidential Enquiries into

Maternal Deaths to be piloted

In spite of these efforts by the government, these interventions are not being widely

publicized and in many districts, community leaders are unaware of these. Further, the

detailed plan for each district to reduce referrals and upgrade health facilities does not

appear to have been shared with civil society organizations till date.

5 Saxena, Deepak, Ruchi Vangani, Dileep V. Mavalankar, and Sarah Thomsen. Inequity in maternal health care

service utilisation in Gujarat: analysis of district-level health survey data. Global Health Action 2013, 6:19652, http://dx.doi.org/10.3402/gha.v6i0.19652 6 Power Point Presentation titled Maternal Death Review – As a tool for System Strengthening-source

www.gujhealth.gov.by Dr N.B Dholakia, Additional Director (FW), Department of Health and Family Welfare

Civil society organizations like SEWA Rural, CHETNA Regional Resource Centre and SAHAJ in

collaboration with ANANDI and Tribhuvandas Foundation (TF) have been doing maternal

death reviews in their own work areas. This report presents a composite picture of maternal

deaths in Gujarat through the civil society lens. Through the present report, Jan Swasthya

Abhiyan seeks to understand the pattern of maternal deaths in different parts of the State

and analyse the gaps in the health system as well as the social determinants that cause

women to die during ante natal period, at the time of delivery and in the post natal period.

It is hoped that this report will complement the initiatives of the health system and lead to

corrective action – by different stakeholders - to prevent such deaths from occurring in the

future. While we hope that the health system will fill the gaps and strengthen maternal

health and emergency obstetric care services, members of Jan Swasthya Abhiyan will also

intensify efforts to enable community action for maternal health.

2. Objectives

1. To determine the pathways leading to maternal death and identifying the health

system and social factors contributing to these deaths.

2. To suggest ways to prevent such maternal deaths in the future.

3. Methodology

This report draws from an analysis of 46 maternal deaths identified and documented over a

period of two years (from January 2012 to December 2013). The deaths are from a

purposive and non representative sample from 11 districts across Gujarat.

Different methodologies were adopted by the three organizations (SAHAJ, CHETNA Regional

Resource Centre and SEWA Rural) involved in documenting the maternal deaths.

ANANDI team has been recording maternal deaths in the field area in a structured manner

since year 2007 with a view to create awareness in community and prevent maternal deaths

in the area. In 2012, SAHAJ in collaboration with ANANDI and Tribhuvandas Foundation (TF)

used the social autopsy tool developed by a group of maternal health activists and

academicians following a national meeting in June 2012 where a framework was developed

to look at maternal mortality in the Indian context (For a more detailed report on the Dead

Women Talking Meeting 2012, refer to www.commonhealth.in). The social autopsy tool was

designed to capture health system gaps, social determinants and human rights violations

that contributed to the maternal death, in addition to identifying a probable medical cause

of death. The tool development process was iterative and the tool was modified based on

feedback from civil society groups' experience of documenting maternal deaths and use of

the tool on the ground.

All deaths of women in the 15-49 years age group were reported by dairy cooperative

volunteers /field level workers in TF and Devgadh Mahila Sangathan women in the field area

of ANANDI. These were then verified by the trained staff of the two organizations to

establish whether they were maternal deaths or not. Following this, the families of the

deceased women – those established as maternal deaths - were contacted by members of

these organizations to do a social autopsy. Information was collected from multiple sources

like ASHA, ANM and Medical officer at PHC, private hospital doctors, and interviews with

the family (both the marital and natal family) were done by a team of two trained

investigators. At least two to three visits were made to complete the social autopsy

interview. Efforts were also made to contact other community members to understand

issues regarding health and other public services and social issues in the community.

The training of these investigators from ANANDI and TF who were staff of the organizations

working on maternal health was conducted by medical doctors (obstetricians), maternal

health activists and academicians. The training included sessions on epidemiology of

maternal deaths, technical inputs on common obstetric complications and their

management, rights based perspectives on looking at maternal deaths and skill based

training on actual use of the tool. Guidelines were adopted to ensure that the information is

captured as a story and does not get lost in the tool format which merely served as a guide

for the investigation.

During the interviews with the family, following a verbal, informed consent, details of the

death were collected using the social autopsy tool.

Similarly, SEWA Rural has been doing maternal death reviews since 2003-04 through a

surveillance system where arogya sakhi (ASHA) or link workers report a death and later

trained supervisory staff and social worker conducts the verbal autopsy making a minimum

of two visits. At present, the organization is using the tool developed by National Alliance

for Maternal Health and Human Rights (NAMHHR) after training by faculty from

CommonHealth. At SEWA Rural, gynaecologists also do facility level enquiries and all

maternal death cases are discussed with the team comprising of clinicians, public health

experts, ASHA, Dai and Anganwadi worker to arrive at possible causes and underlying

factors of a maternal death.

CHETNA as a Regional Resource Centre (RRC) initiated tracking of Maternal Health Services

in underserved areas in 2008 through partners in MNGO scheme. (Please refer

www.chetnaindia.org) In 2012, CHETNA RRC, inspired by a national initiative by

CommonHealth and NAMHHR and ARROW-Malaysia, initiated a process to review maternal

deaths. Action Plans were developed to track all deaths of women in the age group of 15-49

in their area, list their causes and identify maternal deaths. Ten NGOs tracked 229 villages

of 20 blocks in 9 districts of the state for deaths of women in the reproductive age group.

The total population of these villages is 391173. Details of about nine maternal deaths were

collected. These deaths were recorded from a total of 19069 live births, in seven of the

fourteen intervention districts.

For the purpose of producing a state report, available narratives of 46 deaths were compiled

district wise and analysed based on a pre developed framework to identify health system

gaps, social determinants and rights violations leading to the death (see Annexure 1 for a

compilation of the 46 Maternal deaths). During analysis, validation checks were carried out

on the data in the form of checks for internal consistency. The narratives were scrutinised by

two independent teams of Obstetricians to arrive at the probable medical cause of death.

Limitations

1. The purpose of the data analysed here is of advocacy for policy and programmes for

improvement in maternal health care services - it has not been designed as a research

study but as a working document for peer learning.

2. The health activists collected data to understand, analyse and advocate for health sector

accountability in recording, improving and preventing maternal deaths. Efforts have been

made to ensure that the rigour and ethical standards are maintained in the study such as

detailing of case stories and triangulating information from as many sources as possible,

on each case analysed here. The stories, compilation of tables and the report have been

subjected to a thorough scrutiny by four obstetricians and two public health doctors.

3. This documentation has been seen as a qualitative exercise to identify factors that

contribute to maternal deaths and understand those causes. The document captures

some of the maternal deaths in a given area; therefore this is not a report with statistical

information or maternal mortality ratios.

4. The details of these maternal deaths have been collected through interviews with

families who had maternal death in their family. In some cases, interviews with front line

health providers like the ANM and ASHA have contributed to the narrative. However, we

did not have access to the medical records of the women except where the family could

provide copies of some of these records. Thus the analysis draws largely from the

narrative of events provided by the family. Nevertheless this document provides

sufficient material to draw significant conclusions regarding contributors to these

women’s deaths.

4. Findings

Over a period of two years ( January 2012 to Dec 2013), a total of 46 maternal deaths were

documented in 15 blocks of 11 districts of Gujarat, The district wise distribution of these

deaths is depicted in Table 1. Four blocks are in the High Priority Blocks list of Government

of Gujarat.

TABLE 1: District wise distribution of deaths

Districts

Block

Number of deaths in the Block

Total Number of deaths in the district

Dahod Baria 19 19

Panchmahal Ghoghambha 4

5 Godhara 1

Narmada Nandod 1 1

Bharuch Jhagadia 3

4 Valia 1

Anand Anklav 5

7 Umreth 2

Ahmedabad Dhandhuka 1

2 Viramgam 1

Banaskantha Amirgadh 2 2

Kheda Kathlal 1 1

Jamnagar Dwarka 2 2

Navsari Vansda 2 2

Tapi Songadh 1 1

Total 46 46

4.1 Profile of the women who died

Annexure 2, Tables 2 to 6, show the profile of the women who died.

Forty one per cent (41%) of the maternal deaths occur in very young women, below

the age of 25 years – seven were between 16 and 20 years, 12 out of the 46 deaths

were in between 20 and 25 years. This compares with the SRS 2010-12, which states

that 46% of maternal deaths were below the age of 25 years. Almost equal number

was in the age group of 26 to 30 years.

For many of the women, this was either the first (14/46) or the second pregnancy

(13/46). Eleven of the 46 women had between 4 and 8 pregnancies.

More than half – 59 %, i.e. 27 of the 46 deaths were of SC and ST women. This is a

higher proportion than the state’s SC-ST population of around 22 % (2011 Census).

Almost half of the women, who died – 46 % - were illiterate in comparison to 37%

female illiteracy in Gujarat, and majority of the rest – almost one third of the total

were educated only up to primary level. Only 8 of the 46 women who died had

secondary, graduate and vocational education.

Most of the women who died had multiple occupations/responsibilities – in addition

to domestic work, 25 of them were involved in either agricultural work or/and wage

labour. Nine of the women who died migrated for longer than 2-3 months without

safety of home and other basic amenities or any social security.

Three of the women who died were extension workers of the government – a

teacher, a Mid Day Meal in charge and an ASHA worker. One was an LIC agent.

4.2 Details of Deaths

Tables 7 to 11, give details of the Maternal Deaths.

Out of 46 women who died about one third had complications in previous pregnancy

and more than three fourths – 35 women- had complications in the current delivery.

Out of the 46 women, fourteen women (30%) died in the ante natal period, four

(8.7%) during the childbirth and 28 (60.8%) after delivery. Amongst the Post Natal

Deaths, 8 occurred within 24 hours, 3 within a week of the delivery and the rest (17)

between 8 to 42 days of delivery.

Fourteen maternal deaths – (30 %) - took place at home, 24 (52%) in institutions (10

in private and 14 in public institutions); eight deaths (17%) took place in transit. For

details of Place of Birth and Place of Death refer tables 9 and 10.

Table 11 in Annexure 2 shows that out of 46 maternal deaths, direct causes of

maternal deaths were seen in 28 cases (60.86) %) and indirect causes were

responsible for 15 (32.6 %) deaths. Cause could not be determined in 3 cases

(6.52%).

The most common cause of death was PPH (including Ante partum haemorrhage) in

12 (nearly 26 %), followed by Pre-eclampsia in 7 (15.2%), and Pulmonary embolism in

2 (4.34 %) of the women. There were 2 deaths due to sepsis and one death each due

to blood transfusion reaction and obstructed labour.

Among the indirect causes unrelated to pregnancy, anaemia in 4 (8.6%%) was the

commonest followed by 2 deaths each due to jaundice, sickle cell disease and

cardiovascular disease and one each due to malaria, tuberculosis, rabies, renal failure

and dengue.

The cause of death could not be ascertained in 3 (6.52 %) of the deaths.

The table below indicates that in 16 cases , more than one cause of death was

identified like anaemia was associated with 13/41 cases in both direct and indirect

causes of death followed by Cardiac failure (1/41) and PPH (1/41) and Septicaemia

(1/41) were also some of the additional causes of death.

4.2.1 Deaths in Transit

ANANDI

Sr. No. 5- Veena (name changed) died on the way to the referred hospital. She had a

caesarean during her previous delivery and this was her second pregnancy. She

received regular ANC at the Mamta Divas, however received no calcium tablets and

her Hb was not checked. During the 5th month, due to vomiting, she got her BP, Hb

checked at Dr. P’s clinic at Baria and her Hb was reported to be 12 grams. During the

7th month, Veena got labour pain, and was rushed to Dr. P’s clinic on a bike. The

doctor there diagnosed Intra Uterine Death from the sonography reports, and then

informed the family of the urgent need for arranging blood and performed a

Caesarean Section which lasted 6 hours. There was intra op bleeding and she needed

a hysterectomy. She was given two units of blood, which was arranged by the

woman’s husband from Dahod, however there was too much blood loss and post

operation she was referred to another private hospital at Godhara. An ambulance

was called by the doctor, however no referral papers were provided. Doctor informed

the family to arrange for 2 more bottles of blood and 2 bottles of plasma, for which

the husband’s elder brother rushed to Godhara around 5.30 pm. Around 7.30 pm,

on the way to Godhara, near Mendra Chaukdi, the elder brother reached the

ambulance with 2 bottles of blood, which was administered by the nurse to the

woman in the ambulance, however the woman had stopped breathing. She died in

transit, on the way from Dr. P’s clinic at Baria to a private hospital at Godhara.

Sr. No.6- She was married at 16, and this was her first pregnancy. She had only one

ANC and did not have a Mamta Card. Her height, weight, Hb, BP, abdomen was

checked at Dabhva PHC and Hb was reported to be 8 grams. She went into labour at

nine months and was at her natal home for the delivery. The family first called the

Dai and when the pain increased, they took her to a private hospital at Baria, where

she delivered a baby boy. She continued having pain in the legs and stomach post

delivery, and from there she was referred to the District Hospital as she needed

blood. However, the family did not take her to the referred hospital and she died on

the way back from the private hospital to her home. She was diagnosed to have died

due to anaemia in CCF (Congestive Cardiac Failure).

Sr. No. 9- Died on the way from Public Taluka Hospital to Medical College. There was

a delay in diagnosing and managing PPH. She was referred in a very critical condition,

had seizures in the ambulance and died.

Sr.No18- Died on the way from Dr. M’s clinic at Baria to Godhra, which is around 41

km. She was referred in a very critical condition. Lack of care during pregnancy also

worsened her situation; she was working till the ninth month.

SEWA RURAL

Sr. No 1- Died on the way from a Private Hospital to the referred hospital, there

seems to have been unnecessary blood transfusion at the first hospital, which led to

a reaction, and she died on the way to another hospital.

Sr.No.2- Died on the way from home to a local practitioner. She was initially

admitted in the NGO hospital and referred to Medical College, admitted there and

asked to buy medicines, however, the family came back home due to lack of money.

Reason of death was negligence and lack of PN care, and over reliance on local

practitioners.

Sr. No. 5- Died on the way. There was delay in seeking treatment and too many

referrals contributed to the delay, the 108 was late.

Thus we see, that in the 8 transit deaths, it is factors such as lack of Ante Natal care, lack of

Post Natal Care, delay in diagnosis, delay in treatment and referrals and gaps in the health

system that result in death of the woman. Only in two women’s stories it is evident that the

decisions of the family aggravated/ caused woman's death. (ANANDI-Case 6, SEWA Rural-

Case 2).

5. Issues emerging

5.1 Vulnerability of women – high risk assessment?

From the section on the Profile of the Women who died, it is seen that these were highly

vulnerable women on several counts. Many were primis at young age, with very low levels

of education. About 11 women had 4-9 pregnancies.

In addition to their domestic responsibilities, more than 70% of the women were engaged in

farming, as daily wagers and labourers. Some of them worked till the last month of their

pregnancy and this indicates that these women were extremely poor. Majority of them

belonged to scheduled tribes, scheduled caste or other socio economically backward castes,

social groups that have been historically deprived from the development process.

Majority (30 out of 46) of the women who died were very young, in the age group of 21-30

years. Early marriage is a major problem affecting the health of women. DLHS 3 Gujarat

showed that 22.4% of young women were married before they were 18 years, the legal age

of marriage. It is also known that women who have a pregnancy at an age less than 18 face

a high risk of morbidity and mortality. Despite this the narratives reveal that several young

women in the sample had not received any antenatal care at all during their pregnancy. For

example, Maina, a 20 year old adivasi woman was married at the age of 16 and was

pregnant with her first child – she had had only one antenatal visit at the PHC when her

haemoglobin was detected to be low (8 gms/dl), but she was given no iron tablets, no

antenatal card was made either. She later died after delivery, probably because of cardiac

failure due to anaemia (S No.6).

Yet another group of vulnerable women that were not covered by the health system were

migrant workers. At least nine out of 46 women of the sample who died were migrants.

Portability of services was an issue for these women. They were not covered by antenatal

services or ICDS services and when they died their deaths were not recorded as they did not

belong to anyone's “area”. Similarly, the cultural practice of women moving between their

marital and parental homes is not recognised. Portability of maternity services and

entitlements and universal access is an issue.

Vulnerability and resultant high risk pregnancy was also due to socio-cultural factors

perpetuated in the patriarchal society. In Babiben, Amirgarh, Banaskantha district’s case,

son preference was an overarching determinant of maternal death. Babiben was diagnosed

with heart ailment in her earlier pregnancy. She had three children - one boy and two

daughters earlier but had a desire to have two sons and so she went for fourth pregnancy

despite her family being aware of the risk. (Case 3, CHETNA - RRC)

Older women with history of multiple pregnancies (11 out of 46 women had 4 to 8

pregnancies) are a high risk group for complications both because of their age and

multiparity. This group too seemed to be getting left out of care. Urmila is one such woman

– a 32 year old migrant worker in cotton mills, she had a past history of tuberculosis that

had been treated. Of her three previous deliveries, the first one was at a construction site

where she worked and the next two were at home. In her fourth pregnancy, she had had

only one antenatal care visit at a PHC where only a tetanus toxoid injection was given and

she was handed ten tablets of iron folate. No haemoglobin or BP check up had been done.

Urmila subsequently developed severe breathlessness and after desperately seeking care at

seven different facilities over 5 days, her family gave up and took her back home where she

died (Case 4, ANANDI).

These vulnerability factors indicate that ‘high risk’ assessment on purely biomedical terms is

quite inadequate. The peripheral health workers – ASHAs, FHWs, and AWWs – need to be

systematically trained to do early identification of both biomedical high risk and social

vulnerability factors. The multiple dimensions of vulnerability – including the social

dimensions - need to be recognised by the peripheral health workers and need to be

factored into their birth preparedness plan, health care delivery and follow up plans.

5.2 Poor quality of care in community based services - Absent or inadequate antenatal

care

The World Health Organization recommends a minimum of four antenatal care visits for

women with low risk pregnancies. While antenatal care by itself cannot prevent maternal

deaths, it can help in very specific ways – in situations where anaemia continues to be highly

prevalent in pregnancy and contributes to a significant proportion of maternal deaths,

antenatal care can help in diagnosing and treating anaemia before childbirth. In addition,

antenatal care can help screen women who have certain risk factors and need closer

monitoring and care – like those with sickle cell anaemia, mal presentations, previous

caesarean section or previous obstructed labour. The antenatal care session can also serve

as a space where the woman and her family are provided information and counselling

regarding birth preparedness and emergency readiness. It can also serve to foster the trust

of the woman and her family in the public health system.

Availability and Quality of Ante natal Care

Under the National Rural Health Mission, a community based fixed day antenatal care

model has been implemented in the form of Village Health and Nutrition Day. However,

narratives from the family showed that many women either did not receive antenatal care,

or received care that was of very poor quality. Out of 46 women who died, 4 women (Case

9, 10, 22 ANANDI and one from CHETNA RRC) had not received any form of antenatal care

at all.

In many cases ANC is done as tokenism. As the cases below will illustrate, 23 out of 46

women who died, received very poor ANC. Out of 23 women, five had no Mamta Card and

one had falsified information noted in it while some family members even said that ASHA

never visited them (Case 8, ANANDI).

In one case in Dahod (Case 14, ANANDI), even TT was not given to the woman and in two

cases (Case 4 Urmilaben mentioned above, and Case 7, ANANDI) there was no Hb, BP or

weight measured and the woman was given 10 tablets of IFA when she should have been

given the full count of 100 tablets. In yet another case, there were no iron supplements

given at all (Case 17 ANANDI).

Out of 43 cases whose obstetric history was available, 18 were reported to be anaemic. The

fact that so many women were anaemic indicates that there were lapses in ante natal care

and such women were not given iron supplements/iron sucrose injections and were

subjected to high risk pregnancy, and high risk delivery and post delivery period. One

Meetaben, an adivasi woman from Devgadh Baria, Dahod district was diagnosed with

severe anaemia ( Hb 2 gm) in the 7th month of pregnancy which was not treated during her

early ante natal period. She went to a private hospital complaining of swelling and bleeding

and from there was referred to a Civil Hospital. From Civil Hospital, she was further referred

to a private hospital where she was refused admission and finally referred to another

private hospital where she underwent a caesarean section and 4 units of blood were given

but she died soon after that (Case 2, ANANDI). This clearly indicates how severe and

untreated anaemia can be fatal.

One of the other lacunae in the ante natal care is lack of information or counselling given to

women and their families about high risk symptoms or complications during pregnancy,

delivery and post natal period. Out of 46 women, narratives of 10 families indicate that they

lacked information about basic ante natal care. Even in Anand district which is reportedly

well equipped and developed the narratives revealed lack of information given to the

women and their families about complications during pregnancy and post natal period. In

another case in Anand (Case 2, TF) the woman and her family were not guided about the

treatment for TB that needed to be continued in the post natal period.

In Dahod and Panchmahal, the case stories specifically indicate that the women who died did not

receive any information about JSSK, JSY, Kasturba Poshan Sahay schemes (Case 20, 17 ANANDI).

Further, in two cases they lacked information about 108 or did not know how to call it to the village

(Case 6, 24, ANANDI). While access to ante natal care and birth preparedness are key steps in

managing high risk pregnancies; information, access and realisation of maternity entitlements in

form of financial support through the KPSY and free of cost health care services in form of cash,

food grain and support and assistance, are critical.

Portability of Services to ensure Continuum of Care

Due to cultural practice of moving to natal homes during pregnancy ASHA/ANMs lose track

of the women and their checkups and complications before they move out of the village.

Dahiben, aged 22, an adivasi woman, first time pregnant from Vansda, Navsari district

complained of pain and bleeding during pregnancy. She shifted to her natal place and

delivered a still born baby there. Later, she developed complications of disseminated

intravascular Coagulation preceded by Abruotio Placenta and finally died. (Case 8, CHETNA -

RRC)

The summary of the case stories points to how social determinants interact with the ante

natal conditions, especially for vulnerable women, to accentuate their risks for maternal

deaths and morbidities. The vulnerabilities of these women may be a reflection of multiple

social and systemic factors interplaying – however, by not making special provisions to

ensure that these women receive care, the health system adds to their vulnerability.

Quality of ante natal care needs to be improved. In addition to the standard ANC

parameters - haemoglobin, BP, Odema etc for which the understanding and skills of the

health care providers need to be enhanced - better history taking, assessing of social

vulnerability factors needs to be included. Rigorous monitoring of ANC is required – the

supervisors/medical officers need to ask FHWs and ASHAs about follow-up actions for each

high risk and vulnerable pregnant woman.

5.3. Poor quality of care – Absence of Post Partum Care

There seems to be at least some notional effort at providing antenatal care. But postpartum

care seems completely absent both at the levels of the facility and the community. It is well

known that most maternal deaths occur in the first week of the post partum period. Of our

sample of 46 deaths, 28 deaths took place in the post partum period. However, postpartum

care was found to be highly inadequate. Once the woman was discharged from a facility,

there seemed to be no system of providing any care to her.

Usha (name changed) from Anand district, was pregnant for the third time and was regular

in getting her ante natal checkups done. She also got her sonography done. In her previous

pregnancies, she suffered from hypertension and swelling. In her current pregnancy, she

was anaemic, while her BP was normal and weight was reported to be 31 kilograms. She had

loose motions during the seventh month, and there was presence of albumin in her urine.

During the 8th month, she delivered two twin baby girls at a hospital and was discharged

after two days in spite of a premature delivery. She had swelling post delivery and also had

difficulty in breathing; however she was not taken to the hospital. Ten days post delivery

her swelling persisted and she was breathless so was taken to S Hospital where she was

given blood and next day was referred to Karamsad Medical College, wherein she was kept

on oxygen for a few hours and then referred to SSG Hospital, Vadodara. She was taken to

Vadodara by 108 and reached SSG in about two hours, wherein she was declared dead by

the doctor within a few minutes. (Case 1, Tribhovandas Foundation)

Shanti (name changed) went to a private practitioner in Dahod district with breathlessness

and loss of foetal movements – she was diagnosed to have an intrauterine foetal death and

referred to the Civil Hospital. Since there was no doctor there, her family took her to two

different private hospitals before she was admitted in one and delivered a stillborn baby.

After she was discharged and sent home, she developed bleeding on the fifth day; an

ambulance (108) was called the next morning and she was carried the three fourths of a

kilometre on a bed sheet when she died.

These cases highlight that there is no continuity of care after deliveries in health facilities.

There is an absence of any form of post natal care in the villages after childbirth. The front

line workers are unable to recognize postnatal complications. These stories also reflect the

inefficiency and apathy of the government hospitals to give referrals even in such critical

conditions.

Recording of Maternal Deaths - Natal Homes or Marital Home?

As mentioned earlier, several women received partial ante natal care due to socio-cultural

practice of them moving to their natal home during pregnancy. Such mobility not only

affects the quality of care received during pregnancy but in case of death, it also has

implications on the recording of maternal death. There have been instances where the

officials declined to record death if the registration was done in another village.

Shanti (name changed) had conceived after four years of marriage and had been staying

with her parents during pregnancy as her in laws and husband did not treat her well. Shanti

went to Dr. M during 8th month of pregnancy when she experienced breathing problems

and pain in legs; however he confirmed everything to be normal. After a week, when Shanti

stopped feeling baby’s movement and had breathing problems, she was taken to the same

doctor at Baria, who confirmed the death of the baby in the mother’s womb. He asked the

woman’s family to transfer her to the closest government clinic and refused to deliver the

stillborn at his facility. At the government clinic/hospital, no doctor was present to attend to

her so they went to Godhra. The government hospital staff there refused to take her case.

Finally she got admitted in a private facility named Satyanarayan Hospital where she

delivered the still born. Five days after coming home from the hospital, the woman started

bleeding at night, and also complained about loss of appetite and breathlessness. The next

day her family members called an ambulance (108). To avail the service they had to take her

to the main road which was at a distance of 6 kilometres. They carried her in a bed sheet

but she died on her way to the ambulance. Because she was supposed to be a “married

woman” with her marital home in another area, she was not recognised as a resident of her

natal village, although she was registered in Mamta Diwas at the Aanganwadi Centre, the

health department refused to register this death under their PHC area. (Case 7, ANANDI)

Kantaben Rabari (name changed) from Anand district belonged to a pastoralist family and it

was her fourth pregnancy. She had registered at the Anganwadi at her in laws’ village and

had also been given TT here. During the ninth month of pregnancy she went to her natal

home, where she visited the Anganwadi and was informed by the nurse about ‘paleness in

her blood’. No other check up was done. On the 15/01/2013 at 4.00 am, she experienced

labour pains, and gave birth to a baby boy at home. She was assisted in her delivery by her

relatives. Post delivery there was delay in expulsion of the placenta, and there was profuse

bleeding. Around 9.00 am, 108 ambulance was called and she was taken to S Hospital at

Borsad (15 km away). She was admitted and given injections, but died within an hour. (Case

5, Tribhovandas Foundation)

In such cases, we observe a lack of follow up and care by the health functionaries, probably

because of the idea that ‘this woman does not belong in my area’. Poor quality of ante

natal check-ups, coupled with lack of follow up in cases where the women have migrated,

aggravate her vulnerability and inability to seek timely treatment.

The Medical Officers and the Block Health officers need to impress upon the FHWs and

ASHAs that any woman who is pregnant or post natal in their villages, are their

responsibility – they have to provide them all necessary services, keep the requisite records

and report on these cases, just as they would ‘women of their own areas’.

5.4 Referrals and Transport

Women have visited between two and seven facilities before succumbing to death. Around

40 women visited up to three facilities. Here is a story of an adivasi woman who went to

seven facilities over five days to finally die at her home.

Urmila (name changed) from Goghamba, a 32 year old adivasi woman, a migrant worker in

cotton mills was pregnant with her fourth baby. Her first delivery was on a construction site

and other two at home. She had a history of TB which was cured. She went to the PHC (on a

bike) with complaint of breathlessness and was referred from there to the Taluka Hospital

(went across the river 3 kms to the 108 pickup point and from there in 108) and from there

to the District Hospital by ambulance. The doctor at the District Hospital said that he would

not be present during the night and that she should be taken to a private hospital (we don’t

know his or someone else’s). So Urmila was taken home (by chhakda, bus and rickshaw) as

the family did not have money for treatment in a private hospital. By third day the family

was able to arrange for money so they took her to a private hospital in another town (by

bus) and from there to yet another. Here she was told that she had an intra uterine death

and was told to go to the medical college. The family arranged for a private ambulance and

went to the medical college. The next day the doctor in the medical college referred them

to a private hospital in the city. The family decided to just go back home. They went by bus

and chhakda. Urmila died that night at home after five days of being shunted around for

treatment. (Case 4 ANANDI)

Babbiben (name changed) a 27 year old tribal woman from Banaskantha, had a history of a

chest pain in her third pregnancy which subsided after the delivery. In her fourth pregnancy,

she died in the Civil Hospital after visiting six facilities. From the PHC she went to a Trust

Hospital, then to two private clinics, then to the Civil Hospital, from there to a private

nursing home, again to the Trust Hospital and to the Civil Hospital once again. From here

she was referred to Ahmedabad Civil Hospital. A District level Civil Hospital did not have the

life saving services to deal with non-obstetric causes of maternal mortality. Neither did it

have a system of accompanied transfers. (Case 3, CHETNA RRC).

Shanti a 26 year old adivasi woman from Baria (name changed), in her first pregnancy went

to four facilities. Her ANC was done during the Mamta Diwas, BP was normal, Hb was not

done. She was given 10 IFA tablets. She complained of breathlessness during her pregnancy,

went to a private doctor and was told that all was normal. She continued to feel breathless

and felt absence of foetal movements and went to the private doctor once again. He

diagnosed intra uterine death and referred her to the Civil Hospital where there was no

doctor present. So she was taken to a private hospital in the district headquarter where she

was refused treatment. She went to yet another private doctor who delivered a still born

baby. On day 5 after the delivery, she started bleeding heavily. 108 was called in the

morning. She died while being carried on a bed sheet to the ambulance 6 km away. (Case 7

ANANDI).

These families find negotiating repeated referrals and transfers very difficult and ultimately

decide to take the woman back home. Maina from Dahod district got married at the age of

16 and it was her first pregnancy. When the girl complained of pain at 7.00 pm in the

evening, her mother called the dai who examined her and confirmed everything to be

alright. Since the dai was tired, she went to sleep at the girl’s house. After some time, when

the pain became unbearable, the dai advised the family to take the girl to the hospital. Due

to lack of knowledge about calling/ directing 108 ambulance to their location, they couldn’t

avail the service. They finally left for the facility at 5.00 am in a private rickshaw. She was

taken to Dr. M’s Clinic at Bariya. As per ANANDI field staff the reason for concern was ‘green

water’. When the doctor checked her eyes and tongue, he sent her to the lab first for the

investigation and then she was transferred to the delivery room where she gave birth. Post-

delivery the mother kept complaining about pain in stomach and feet. Doctor referred her

to Godhra district hospital for blood. However, the woman’s family members found the

process of transfer difficult and decided to take her back to the village in the same rickshaw

at 10.00 pm. On her way to the village, the girl had stopped talking and was believed to be

dead before reaching home. (Case 6, ANANDI).

Many of the stories indicate that women and their families prefer to go to the private

doctors rather than to public facilities. From the private, even from Chiranjivi doctors, they

are referred to public and they choose once again to go private facilities or simply to go

home (Case 6 CHETNA RRC, ANANDI). There have been situations when doctors have not

been present in the public hospitals (Case 5 SEWA Rural, Cases 1, 7 and 8 ANANDI).

What is astonishing is how the Medical College doctors as well as the Civil Hospitals in the

districts are sending women away to private hospitals. (Case7 and Case 13, ANANDI).

Another noteworthy issue is the lack of coordination between health care facilities – both

the referring facility and the one where the woman is being referred. (Case 3, Case 12, Case

18 CHETNA RRC). There is absence of any referral protocols, documentation or even

accompanied referrals.

We did find a couple of positive case studies of accompanied referral. Veena (name

changed) BA B.Ed, in her second pregnancy went into pre term labour at 7 months. Intra

Uterine Death was diagnosed in a private hospital. She was taken for a Caesarian Section

which lasted 6 hours. There was intra operative bleeding, and she needed a hysterectomy.

She was given 2 units blood, and referred to another private hospital in District HQ with

ambulance, nurse and blood (2 units more + 2 plasma given in the ambulance). However she

died in transit. (Case 5 ANANDI). Kamla (case study is in the next section) was also

accompanied by a doctor and nurse in 108, but to no avail – the lapses in the 108 service

were too many.

Transport

Analysis of these case studies points also to the fact that although 108 has helped to

increase access to health services for many women; many especially vulnerable women in

remote areas continue to be plagued by lack of physical access and transport facilities.

Denial and availability of transport at affordable rate and full reimbursement of expense

incurred for hospitalisation as well as return journey home remains a common complaint.

Case 2 (ANANDI) had severe anaemia in ante natal period, which was not treated. She went

with swelling to a private hospital from where she was referred to the Civil Hospital. Here

she was induced labour and referred to the District Hospital due to bleeding. Strangely the

family was not provided with ambulance, vehicle or assistance to deal with the emergency. .

She went to a private hospital in a private vehicle where she was refused admission. So she

went to another private hospital in the District Headquarter where a CS was done. She was

given 4 units of blood but died soon after. Case 2 (ANANDI) states that ‘Ambulance not

provided, 108 refused to come.

‘There are many situations where the 108 has come late (Case 5 SEWA Rural, Case 8

ANANDI). ‘A woman who went into labour at term, called 108, had to wait 2 hours for it. She

was carried to it in a bed sheet for 3/4th kilometre till the main road, where it stood. She was

taken to the Taluka Hospital where she was assigned a bed and given an injection by the

nurse. The doctor was not present there, and the woman was kept waiting. She couldn’t

survive that long and died unattended. (Case 8 ANANDI)

Kamla’s case from Narmada District (name changed) is the epitome of how things can go

wrong for a woman due to 108. ‘She was a 24 year old graduate. She had a normal delivery

at home before the dai could arrive. There was profuse bleeding. 108 was busy so another

108 had to come from 70 km away and came after 1 ½ hrs. She was unconscious by then.

108 took her to the CHC, no doctor or nurse was present there. So she was taken to a

private nursing home where she was admitted and given 5 units blood. Feeling

breathlessness on Day 2, she was referred to another private hospital, where she was given

1 more unit of blood. But her condition worsened. So she was referred to the medical

college after 11 hours, in 108, but the vehicle broke down in between. Another 108 was

called and she was taken to the medical college (the doctor and nurse accompanied her),

but she died before reaching there’. (Case 5 SEWA Rural). In the area of Anand where the

maternal deaths were documented, it was observed that 108 have not been used often.

There appears to be lack of adequate information about this facility and pregnant women in

situations of emergency have taken auto rickshaws.

5.5 Out of Pocket Expenses.

Despite the Chiranjivi Yojana and the JSSK, the guarantee of free and cashless service for

childbirth is a hollow promise. Where ever the question on Out of Pocket Expenditure has

been asked, the response from the families has been ‘yes’. Expenditures have ranged from a

low of Rs. 990 to over Rs. 20,000, with a number of families having incurred between Rs.

17,000 and Rs. 19,000. In Anand district, four out of the seven women who died after

seeking services at multiple facilities, incurred Rs. 20,300, 19,000, 7,000, and 17,000 (Cases

1 to 4 Tribhuvandas Foundation). TF Case 3’s story states that she was a 24 year old woman

with anaemia in previous pregnancy as well as the current one. Lack of information on high

risk symptoms like PPH, no Mamta Card, no blood facility in government hospital due to

which she was referred to a private hospital where they could not pay for the blood (she

was given 4 units of blood). She was discharged early, after 12 hours of delivery from the

hospital, no post natal care given by the system. So they brought her back home. She died

at home.

Stories of denial of services because of lack of money with the family are not uncommon.

Cases 2 and 11 ANANDI are two such stories. Meeta (named changed) an agricultural,

migrant labourer, whose both earlier children had died in their infancy, was severely

malnourished and anaemic (other symptoms included night blindness and Hb 2 gms %). Her

severe anaemia in the ante natal period was not treated. She went with swelling to a

private hospital and from there was referred to a Civil (sub district hospital) Hospital. Labour

was induced in the Civil Hospital. And she was referred to District Hospital due to bleeding,

but was not given any vehicle. They took a private vehicle to a private hospital where she

was refused admission. From there they went to another private hospital in the District

Head quarter where a CS was done – 4 units of blood was given, but she died soon after.

Her family reported that they spent Rs. 19,200 before she died - she was ‘severely anaemic,

yet was not provided blood during initial check up due to lack of money’. (Case 2 ANANDI).

Sheelaben’s (name changed) first three babies died, in the current pregnancy she had fever

in the 5th month, and pain in the 7th month. She visited three facilities – there was an

incorrect diagnosis by the first doctor (breech position was not diagnosed), and then she

was referred in an emergency. Dr. XYZ’s Hospital did not admit her till both money and

blood were arranged. Responsibility of arranging for the blood as always was put on the

family. (Case 11 ANANDI).

It is not only at the private practitioners that families have to incur out of pocket

expenditures. Even at government medical college hospitals, women have to spend on child

birth. The story of Case 2 SEWA Rural goes like this: She was admitted in the NGO hospital

with severe anaemia and dengue. With no improvement even after 10 days, she was

referred to the medical college (ambulance), where she was admitted and asked to buy

medicines for Rs 11000 from outside. The family came back home since they had no money.

She had a pre term delivery the next day. There was fever and swelling after that. She was

shown to a local practitioner on Day 7 after delivery. He gave her IV Fluids and an injection.

Her condition worsened 4 days later and she died while being taken to the local practitioner

on a bike.

Cashless services have to be provided to pregnant women. Otherwise, reimbursement of all

expenses has to be made part of the system. Grievance redressal mechanism need to be

clearly communicated to families so that they have a forum to complain and get their

complaints satisfactorily addressed.

5.6 Lack of support for arranging Blood

One way of reducing maternal mortality is by improving the availability, accessibility, quality

and use of services for the treatment of complications that arise during pregnancy and

childbirth, services such as EmOC (Emergency Obstetric Care). Arranging for blood in

emergency situations was one of the areas that families were held responsible for. Blood

transfusion can be a life saving medical procedure in certain medical emergencies like

haemorrhage and shock. Also, women with severe anaemia in late pregnancy may need

blood transfusion. In the narratives, it was seen that in situations of emergency, blood

transfusion was either delayed or inadequate – this was because the responsibility of

arranging for blood is considered to be that of the family’s. Poor families of the deceased

women often had to pay enormous sums in addition to finding donors at short notice to

arrange blood.

Gayatri (name changed) from Dahod district suffered from swelling in her legs during the

sixth month of her first pregnancy. She was admitted at a private clinic at Godhra, and given

medicines, and then readmitted at S Hospital. A month later she was taken to P Maternity

Home at Godhra, where check up showed 7.9% Hb and sonography showed twins. Doctor

said that blood was needed, which couldn’t be arranged at Godhra so they came back

home. Her husband refused to donate blood. They came back to Godhra, admitted her to P

Maternity Home for 2 days and then took her to Baria Civil Hospital by ambulance (108).

They stayed there the entire day and were assured that she would get well, however no

doctor came to check on her at night. So next day, early morning around 6.00 am they took

her to L’s private clinic where they were informed that her condition was very critical.

Gayatri’s father, brother and uncle went to the Indian Red Cross Society to arrange for blood

but in the meantime she died. (Case 13, ANANDI)

Jyoti (name changed) from Anand district was pregnant for the second time and was

severely anaemic. She was given iron supplements by the ASHA; however she had not been

consuming them as informed by the family. During her ninth month, she was admitted at N

Hospital as she was suffering from cold, cough and very low Hb. She was given four bottles

of blood in two days and then discharged. A few days later, she complained of labour pain.

Due to lack of blood facility in the government hospital, she was re admitted in a private

hospital, where she delivered a baby boy. However, she was severely anaemic, and the

family could not pay for the blood. So her family requested for discharge from the hospital

the next day. Four days later, the woman complained of breathing problems and died at

home due to excessive loss of blood. (Case 3, Tribhovandas Foundation)

In cases recorded above, no observation and follow up during the post natal period, coupled

with insufficient EmOC facilities, and support for blood, led to woman’s death. Non

availability of blood due to lack of arrangements at the facilities- public and private seemed

a common phenomena which has been instrumental in delayed treatment, inadequate

care and issues of quality care are some of the commonly prevalent factors in most cases

of maternal mortality. Availability of blood has to be assured for all pregnant women. This

also has to be part of birth preparedness. Families, communities, college students, youth

groups, need to be mobilised for blood donation regularly.

5.7 Role of Public Health Facilities in Emergency Obstetric Care

The role played by a range of public health facilities – CHCs, Taluka Hospitals, Civil Hospitals,

District Hospitals as well as the Medical College Hospital - in these 46 stories is rather

distressing. The question which comes up is whether there are any protocols, standard

procedures and practices to ensure Comprehensive Emergency Obstetric Care that is

guaranteed in each district. What are the accountability mechanisms to ensure that each

level of the health delivery system discharges its role in provision of Emergency Obstetric

Care in the most responsible manner? Where and what are the checks and balances?

As mentioned earlier, many pregnant women and their families experienced that the

medical and para medical staff was not present at the time of hospitalisation in CHCs, Taluka

Hospitals, Civil Hospitals. This could contribute to the trust deficit that exists vis a vis the

public health system forcing people to find their way to other health facilities, in situations

of emergencies. Even where doctors were available in the hospital, in some cases there was

denial of services to patient. In a District Hospital the doctor present actually told the family

that he would not be there at night and that they had better take the woman to another

facility (a private hospital) Case 22 (ANANDI) states that Rs. 5000 was demanded in the

government hospital for an operation. Case 4 (ANANDI) states that there was denial of

services at various levels of the public health system. Most amazing was referral of a

woman from a medical college hospital to a private hospital!!

Case 3 TF is about lack of availability of blood in a government facility and the family having

to take the woman to a private hospital. Case 3 CHETNA RRC was about lack of life saving

care at the District Hospital for non obstetric care. Case 4 CHETNA RRC was about the

inability to administer the anti rabies vaccine. Case 8 ANANDI – the woman was left to die

unattended at the Taluka Hospital.

Continuum of care through the public health structure has been a problem. Case 2

Tribhuvandas Foundation states that the woman’s TB was not detected early enough in the

pregnancy. Similarly Case 7 Tribhuvandas Foundation was about late diagnosis of high risk

symptoms like the negative blood group, cardiac problems, and high BP. In Case 6

Tribhuvandas Foundation, the PHC nurse does not measure the BP and refers to SSG in

Vadodara and the woman dies on the stretcher. Thus failures to identify areas of concern in

the ANC period and not being able to communicate these to higher levels of care

jeopardises women’s lives. Similarly, when women fail to attend the follow up sessions

after crises, there is no follow up from the health system or any home visit.

Regular monitoring of maternal deaths and near misses, with the perspective of learning

from them and not fixing blame, and periodic meetings with community leaders and CBOs,

will help to build trust and complementary action to prevent maternal deaths.

6. Conclusion and Recommendations

This report shows the rather unacceptable state of affairs with women dying - in many cases

– needlessly, in the process of child birth in an otherwise progressive state like Gujarat. The

situation for marginalised and vulnerable women is rather grim – social, economic, and

cultural factors interact to compound their vulnerability. Early marriages and childbirths,

poor nutritional status and anaemia, physical work overload, poverty, and gender issues put

these women at grave risk during pregnancy, childbirth and after the child birth. Health

system factors like inadequate and less than satisfactory quality of ante natal care, weak

transport systems (despite the introduction of 108), poorly functioning health care facilities

from the Sub Centre, PHC, CHC, Civil Hospitals, District Hospitals, difficulties in accessing

emergency obstetric care including blood, non- existent Post Natal Care - all contribute in a

compounded way to Maternal Deaths.

Some of our recommendations are:

Ensuring quality ante natal care. In addition to the standard ANC parameters -

haemoglobin, BP, Odema etc for which the understanding and skills of the health

care providers need to be enhanced - better history taking, assessing of social

vulnerability factors, appropriate counselling for family members especially

husbands, needs to be included. Rigorous monitoring of ANC is required – the

supervisors/medical officers need to ask FHWs and ASHAs about follow-up actions

for each high risk and vulnerable pregnant woman. Community monitoring also

needs to be encouraged and institutionalised in a way that the health system feels

supported, and not threatened.

Ensuring sensitivity to social determinants and an understanding of high risk as going

beyond the bio medical factors, to include the various social determinants like young

age, literacy status and gender issues. Ensuring that these high risk women are

carefully followed up and supported through their pregnancies, childbirth and post

natal period. The peripheral health workers – ASHAs, FHWs, and AWWs – need to be

systematically trained to do early identification of both biomedical high risk and

social vulnerability factors. The multiple dimensions of vulnerability – including the

social dimensions - need to be recognised by the peripheral health workers and need

to be factored into their birth preparedness plan, health care delivery and follow up

plans.

Educating families for Ante Natal Care - the importance of each component as well as

the rationale - about high risk symptoms during the ante natal period, at labour and

during post natal period. While access to ante natal care and birth preparedness are

key steps in managing high risk pregnancies; information, access and realisation of

maternity entitlements in the ICDS, financial support through the KPSY, JSSK, JSY,

Chiranjeevi Yojana and free of cost health care services in form of cash, food grain

and support and assistance, are also critical.

Ensuring action to address malnutrition and anaemia in women and girls –

uninterrupted consumption of IFA, iron sucrose, good quality and adequate PDS and

ICDS take-home-rations.

To make Skilled Birth Attendance closer to women, functioning Sub Centres with safe

delivery services with a supportive role for local resources, like the trained traditional

dais that the women trust.

Accountability and governance of the public health institutions is of utmost

importance. As mentioned above, supportive supervision from within the system is

required for problem solving to ensure functioning and responsive Basic Emergency

Obstetric Services at each PHC and Comprehensive Emergency Obstetric Services at

the CHCs, Taluka Hospitals, and District Hospitals.

Ensuring continuum of care through two way communication and referral systems

between health facilities and the community – this will also address post natal care

of women who have delivered in facilities and help reduce the post natal maternal

deaths.

Similarly, ensuring systems of portability of services and entitlements and

disseminating information widely on these.

Assured availability of blood at short notice without making this the families’

responsibility. Organisation and promotion of blood donation camps at community

level.

Cashless services have to be provided to pregnant women. Otherwise,

reimbursement of all expenses has to be made part of the system. Grievance

redressal mechanism need to be clearly communicated to families so that they have

a forum to complain and get their complaints satisfactorily addressed.

Streamlined referral systems that are accountable, based on referral protocols -

written referral slip, phone calls to facilities where the woman is being referred,

accompanied transfers, stabilising the woman with first aid before referring her.

Good quality timely post natal care at facility as well as at household level.

Birth preparedness which includes that referral may be required and a decision

maker should be present. This should also include that blood transfusion may be

required – family and community members should be prepared to donate blood or

arrange for it at short notice. Phone numbers of emergency transport and referral

services should be available with the family. The individual vulnerability factors

should be discussed and birth preparedness should be done to minimise impact of

her vulnerability on her health and pregnancy outcome.

In addition, we would like to recommend that civil society organisations including local

sangathans and peoples’ organisations, panchayats/gram sabhas, VHSNCs should be

involved so as to increase maternal death reporting. NGOs/CSOs should also become part of

the MDR teams so that they can complement the MDRs with a social and community

perspective. NGOs and CSOs should also be part of the MDR Committees at the District

level so that they can take back the lessons from MDR analysis to the communities – this

can increase community consciousness of their responsibility for maternal health.

Discussions on Maternal Health and Maternal Deaths should become a public issue – all

stakeholders must act to promote maternal health! Community leaders and CBOs have an

important role to play locally to prevent maternal deaths and promote maternal health.

NGOs have a role to facilitate dialogue and coordination between community groups/CBOs

and health system at all levels, as well as to support community action for maternal health.

Annexure 1

Annexure 2

TABLE 1: District wise distribution of deaths

Districts

Block

Number of deaths in the Block

Total Number of deaths in the district

Dahod Baria 19 19

Panchmahal Ghoghambha 4

5 Godhara 1

Narmada Nandod 1 1

Bharuch Jhagadia 3

4 Valia 1

Anand Anklav 5

7 Umreth 2

Ahmedabad Dhandhuka 1

2 Viramgam 1

Banaskantha Amirgadh 2 2

Kheda Kathlal 1 1

Jamnagar Dwarka 2 2

Navsari Vansda 2 2

Tapi Songadh 1 1

Total 46 46

These maternal deaths are reported from 15 blocks of 11 Districts. Four of these blocks are

in the High Priority Blocks list of Government of Gujarat.

TABLE 2 - Age distribution of the women

Age (years) Number of women %

16 – 20 7 15.21

21 – 25 12 26.08

26 – 30 18 39.13

31 – 35 8 17.39

36 – 40 1 2.17

Total 46

Most maternal deaths occur in very young women – 19 out of the 46 deaths were in young

women below the age of 25 years. Almost equal number was in the age group of 26 to 30

years.

TABLE 3 – Caste distribution of the women

Caste Number of women %

SC 6 13.04

ST 21 45.65

OBC 19 41.30

Total 46

More than half, i.e., 27 of the 46 deaths were of SC and ST women.

TABLE 4- Educational attainment of women

Educational Level Number of women %

Illiterate 21 45.65

Up to primary 16 34.7

Secondary 3 6.52

Graduate 2 4.34

Others (Vocational Training, computers, PTC, etc)

3 6.52

No Data 1 2.17

Total 46

Almost half of the women who died were illiterate and majority of the rest – almost one

third of the total were educated only up to primary level. Only 8 of the 46 women who died

had secondary, graduate and vocational education.

TABLE 5- Occupation of the women

Occupation Number of women

Solely Housework 12

Domestic work and wage labour

5

Migrant labourer 9

Domestic work and farming

8

Agriculture, wage labour & domestic work

8

Agriculture, domestic work & migrant labourer

2

Others (Teaching, mid day meal in charge, LIC, ASHA, etc)

4

No data 2

Total 50*

Most of the women who died had multiple responsibilities – in addition to domestic work,

23 of them were involved in either agricultural work or/and wage labour, nine of them as

migrant workers. Three of the women who died were extension workers of the government

– either a teacher, Mid Day Meal in charge or an ASHA worker. One was an LIC agent.

*Multiple responses so the change in N

TABLE 6 – Number of pregnancies

Number of pregnancies Number of women %

1 14 30.43

2 13 28.26

3 8 17.39

4 – 5 9 19.56

6 – 8 2 4.34

Total 46

For many of the women, this was either the first (14/46) or the second pregnancy (13/46).

TABLE 7- History of Obstetric complications

Obstetric complications Number of women

Previous pregnancy 16 (data not available for some)

Current pregnancy 35

Data unavailable 4

No complications 2

Out of 46 women, about one third had complications in previous pregnancy and more than

three fourths of the women had complications in the current pregnancy.

TABLE 8 - Time period of death

Time Period of death Number of Women %

Antenatal 14 30.43

Intra natal 4 8.69

Postpartum 28 60.86

Post abortion None -

Total 46

Fourteen women died in the ante natal period, four during the childbirth and 28 after

delivery.

TABLE 9 - Place of death

Place of death Number of women Percentage

Home 14 30.43

Health Facility 24 52.17

Public 10 41.6

Private 14 58.3

On the road 8 17.39

Home to first facility 1 12.5

One facility to another 6 75

Facility to home 1 12.5

Total 46 100.0

Fourteen maternal deaths took place at home, 24 in institutions (10 in private and 14 in

public institutions), eight deaths took place in transit.

TABLE 10- Place of Delivery/ Place of Birth

Place of Birth Number of women

Percentage

Home 10 21.7

Hospital 23 50

Public facility 9 19.56

Private facility 14 30.43

Data unavailable 1 2.17

Not applicable 12 26.0

Total 46 100

Out of the 46 cases interviewed for the study, 10 women delivered at home, 23 women

delivered at hospital, with 9 women delivering at a public hospital while 14 women

delivering at a private hospital. The data was not available for 1 case.

TABLE 11 - Probable medical cause of death

Out of forty six deaths that were analyzed and validated by medical experts, ten case stories

were not available for ascertaining the cause of death but probable causes have been

identified and included in the data below.

Table 11 a) Probable medical cause of death

Sr. No Type of cause N (44) %

1 Direct causes 28 60.86 2 Indirect causes 15 32.60

3 No data 3 6.52

Total 46 100

Out of 46 maternal deaths, deaths due to direct causes constituted 28 (60.86%) of deaths and

indirect causes were responsible for 15 (32.6%) deaths.

Table 11 b) - Details of Causes of Deaths

Sr.

No

Type of cause

N(46)

1 DIRECT CAUSES

N %

Haemorrhage (intrapatum, postpartum,Ante Partum) 12 26.08

Eclampsia ,Preeclampsia 7 15.21

Pulmonary Embolism 2 4.34

Sepsis 2 4.34

Blood transfusion reaction 1 2.17

Obstructed labour (Breech baby ) 1 2.17

CCF 3 6.52

Total 28

2 INDIRECT CAUSES

Anemia 4 8.6

Sickle cell Disease 2 4.3

Jaundice 2 4.3

Cardiovascular disease 2 4.3

Dengue/infection

1 2.1

Malaria 1 2.1

Tuberculosis 1 2.1

Renal failure 1 2.1

Rabies 1 2.1

Total 15

3 No data 3 6.52

Total 46 100

The most common cause of death was PPH (including Ante partum haemorrhage) in 12 (nearly 26

%), followed by Pre-eclampsia in 7 (15.2%), and Pulmonary embolism in 2 (4.34 %) of the women.

There were 2 deaths due to sepsis and one death each due to blood transfusion reaction and

obstructed labour.

Among the indirect causes unrelated to pregnancy, anaemia in 4 (8.6%%) was the commonest

followed by 2 deaths each due to jaundice, sickle cell disease and cardiovascular disease and one

each due to malaria, tuberculosis, rabies, renal failure and dengue.

The cause of death could not be ascertained in 3 (6.52 %) of the deaths.

The table below indicates that in 16 cases , more than one cause of death was identified like

anaemia was associated with 13/41 cases in both direct and indirect causes of death followed by

Cardiac failure (1/41) and PPH (1/41) and Septicaemia (1/41) were also some of the additional

causes of death.

Table 11 c) Additional Causes of death

Sr.No Cause Number

1. Anaemia 13

2 PPH 1

3 CCF (Congestive Cardiac failure) 1

4 Septicaemia 1

Total 16

TABLE 12 – Comparative table of probable cause of death and time period of death

Time of death

Probable medical

cause of death

Post

abortion

Antenatal

(14)

Intra-natal

(4)

Postpartum

(28)

Total

DIRECT CAUSE

Haemorrhage

(intrapatum,

postpartum,Ante

Partum)

0 2 1 9 12

Eclampsia

,Preeclampsia

0 2 0 5 7

CCF 0 1 0 2 3

Pulmonary Embolism 0 1 0 1 2

Sepsis 0 0 0 2 2

Blood transfusion

reaction

0 0 0 1 1

Obstructed labour

(Breech baby )

0 1 0 0 1

INDIRECT CAUSES

Anemia 0 1 1 2 4

Sickle cell Disease 0 1 0 1 2

Jaundice 0 1 0 1 2

Cardiovascular

disease

0 1 1 0 2

Dengue/infection

0 0 0 1 1

Malaria 0 1 0 0 1

Tuberculosis 0 0 0 1 1

Renal failure 0 0 0 1 1

Rabies 0 1 0 0 1

No data 0 1 1 1 3

Total - 14 4 28 46

TABLE 13 – Comparative table of probable cause of death and place of death

Place of Death

Probable medical

cause of death

Health

Facility

Home Transit Total

DIRECT CAUSES Public Private Home

to first

facility

One

facility

to

another

Facility

to

home

Haemorrhage

(intrapatum,

postpartum,Ante

Partum)

1 4 2 1 4 12

Eclampsia

,Preeclampsia

3 4 7

CCF 1 1 1 3

Pulmonary Embolism 2 2

Sepsis 2 2

Blood transfusion

reaction

1 1

Obstructed labour

(Breech baby )

1 1

INDIRECT CAUSES

Anemia 1 2 1 4

Sickle cell Disease 1 1 2

Jaundice 1 1 2

Cardiovascular

disease

1 1 2

Dengue/infection

1 1

Malaria 1 1

Tuberculosis 1 1

Renal failure 1 1

Rabies 1 1

No data 3

Total 9 13 13 1 6 1 46

Sr. No 7, TF. 1 death at home, not included in table as cause could not be

ascertained, the cause is mentioned as fever which is incomplete information.

Sr. No 8, ANANDI, death at Public Facility, not included in table as cause of death

could not be ascertained.

Sr. No 17, ANANDI, death at Private facility not included in table as cause of death

could not be ascertained.

Annexure 3