Country case study
Achieving millennium development goals 4 and 5: a snapshot of life in rural India
Dr SS Mullick, Khristiya Seva Niketan Hospital, Sarenga, Bankura District, 722150 West Bengal, India. Email email@example.com
Please cite this paper as: Mullick SS, Serle E. Achieving millennium development goals 4 and 5: a snapshot of life in rural India. BJOG 2011;118 (Suppl. 2):104–107.
The case studies presented here illustrate the poignant reality of life for mothers and children in rural India. We highlight the challenges of achieving millennium development goals (MDGs) 4 and 5, by exploring the reasons behind maternal and childhood mortality using the three-delays model as a framework. Gender disparities, lack of empowerment of women, poor understanding of life-threatening illness, the inability to know when and where to seek help, security issues, deficiencies in understanding cultural perceptions, poorly equipped health facilities and a lack of skilled personnel are all highlighted.
The Government of India is committed to tackling the appalling health statistics of the rural poor, and of the scheduled caste and tribal peoples, which significantly contribute to the global mortality rates of mothers and children under the age of 5 years.1
Khristiya Seva Niketan Hospital is a 150-bed general hospital in the Santal tribal belt of West Bengal serving a population in which upwards of 70% are below the poverty line. The hospital, a charitable non-governmental organisation, is the only major hospital within a radius of 60 km. By Western standards it is poorly equipped and poorly staffed, but the hospital supports a nursing training school that runs a 3-year general nursing and midwifery training programme recognised by the West Bengal and Indian Nursing Council.
A delay in accessing care can occur at three time points. This has been described as the three-delays model: the first delay refers to a woman or her family delaying the decision to seek care; the second is the delay in reaching that care; and the third is the delay in receiving care once a healthcare provider is reached.2 In this paper we use the three-delays framework to highlight the challenges and examine the possible solutions to achieving millennium development goals (MDGs) 4 and 5 in a rural Indian setting.
Three case studies
Delay in seeking care
Madhumita was a 19-year-old primigravida. She attended the antenatal clinic regularly from 14 weeks of gestation. She could not afford an ultrasound scan but clinically her size was in keeping with gestational age. She developed chicken pox at around 30 weeks of gestation, which was complicated by a chest infection. She was managed as an outpatient by choice.
At 37 weeks of gestation, although normotensive, with a blood pressure (BP) of 120/80 mmHg (booking BP 110/70 mmHg), Madhumita had pre-tibial pitting oedema. Her urine showed 1+ proteinuria. She had no epigastric tenderness and was not hyperreflexic. Her baby seemed to be growing well, with a fundal height of 35 cm, a longitudinal lie and cephalic presentation with 3/5 per abdomen. Admission for observation was advised, but when Madhumita discussed this with her husband and mother-in-law, they could not see the necessity and would not allow her to be admitted to hospital. She was counselled about the warning symptoms and signs of eclampsia, and was advised to come to the hospital immediately if any new symptoms arose. A follow-up antenatal appointment was arranged for the following week.
It was heartbreaking when Madhumita was brought to the hospital a few days later, in severe respiratory distress, and agitated, with a BP of 200/120 mmHg. Treatment with nifedipine and an intravenous infusion was commenced, but she developed acute respiratory distress and quickly became unconscious and died before more senior help arrived.
Neither Madhumita nor her family believed that her life was at risk, nor did they recognise the complications when they arose, until it was too late. The opportunity of saving Madhumita’s life was missed. We felt we had failed her and needed to find new ways in which we could communicate more effectively with women, families and communities, to gain their full trust and understanding. Everywhere, but particularly in this setting, it is important to find ways to promote an ethos of shared responsibility and partnership for the care of women and newborns throughout pregnancy, childbirth and the postnatal period.
Delay in receiving care
Phulmani, a primigravida, had a good rapport with her auxiliary nurse midwife, who she had been seeing regularly at her local primary health centre. When her labour pains started, Phulmani went straight to the primary health centre, but because of hypertension and slow progress she was transferred to hospital for ‘better management’.
Labour was augmented with amniotomy and oxytocin, but at full dilatation fetal heart decelerations were noted and the medical officer was called. He attended the patient but did not possess the skills to carry out an assisted vaginal delivery. Sadly, Phulmani delivered a fresh stillborn male infant around half an hour later.
Following delivery, Phulmani’s blood pressure remained poorly controlled and a 5-mg tablet of nifedepine was prescribed, but Phulmani lost consciousness 24 hours later. It took a further 24 hours for a diagnosis of eclampsia to be made and for treatment with magnesium sulphate to begin, but she suffered repeated convulsions and died a few hours later.
Access to good antenatal care and a prompt referral from the primary health centre meant that Phulmani got to the hospital promptly. In spite of guidance having been given to medical and nursing staff regarding fluid management in hypertensive patients, and indeed in any patient requiring oxytocin in labour, 5% dextrose was prescribed by the medical officer on duty, and the nursing staff did not have the confidence to challenge this decision. The hierarchy between medical and nursing staff posed a challenge to teamwork in this case. Fetal distress was correctly diagnosed using a Pinard stethoscope, but adequate medical expertise to carry out an assisted vaginal delivery at full dilatation was unavailable.
Although not vital in this case, delays in diagnosis and the instigation of management are often exacerbated by the paucity of available laboratory investigations. Problems with the wider infrastructure, such as a lack of communication between staff resulting in a delay in theatre mobilisation, could be addressed by the use of mobile phones. Challenges such as low-voltage, poor lighting or sudden power failure could be addressed with back-up generators, which are not often present.
Limited numbers of staff means exhaustion from long working hours, heat and humidity. This needs to be addressed by workforce planning, deployment and retention of staff, as well as ensuring the updating of skills in emergency obstetric care. Furthermore, there is sometimes a somewhat fatalistic attitude amongst both staff and patients that predisposes them to inertia in emergency situations. In our setting, families often demand input from doctors and have a low regard for the nursing profession. This needs to be addressed by promoting better teamwork, a less hierarchical structure and the up-skilling of staff.
The three delays
Sujit, a 4-year-old motherless boy from a remote jungle area, was staying in his maternal uncle’s home when he developed a cough, which soon got worse. He was taken to a traditional/herbal doctor because the treatment was cheap. Two days later, when he did not improve, the family decided to bring him to our hospital, as they had heard good reports about the care there. Unfortunately, the area where he lived was dominated by ultra-leftist revolutionaries, who imposed a curfew restricting vehicular access in that area. Three days later, the curfew was lifted, but by the time he made the 80-km journey to the hospital, Sujit was severely distressed, agitated, struggling for breath, coughing up blood and essentially moribund. He was seen by the paediatrician who happened to be in the hospital at the time. There is no permanent paediatrician, nor for that matter any specialist, in this hospital.
Oxygen was delivered via nasal cannula, as there was no piped oxygen. The family had to borrow money and use free ‘physician’s samples’ (promotional drugs given by pharmaceutical companies) to keep the cost of care for Sujit to a minimum. The hospital did not have facilities for running blood culture and sensitivity tests, liver function tests, clotting studies, C-reactive protein tests or ultrasound scans. Sujit was severely undernourished, with a haemoglobin level of 7 g/dl. Management was essentially supportive, and gradually he responded to the antibiotics, physiotherapy and humidified oxygen. Sujit made a full recovery and returned home after a week. His own mother had died at home from postpartum haemorrhage shortly after his birth. His siblings had died at the ages of 4 and 6 years, after fever-related illnesses. Sujit’s paternal grandmother (his main career) was distraught that she might also lose him. Since returning to their community, members of the extended family and friends have come to the hospital for treatment, at the recommendation of Sujit’s family.
In this case, there are examples of all three delays. Sujit’s family first went to see a non-skilled healthcare provider, an example of a type-1 delay. He could not access a health facility because of delays resulting from a conflict-generated curfew. War and conflict can also result in transport problems associated with landmines and fear of attack.3 Despite a lack of finances and a lack of optimal treatment options (an example of a type-3 delay), Sujit was lucky that low-cost measures saved his life.
Opportunities to address the three delays
A recent Indian government initiative has resulted in the opportunity for women living below the poverty line to receive free care for the delivery of their babies, provided that their treatment takes place in a healthcare facility.4 Before this initiative, many families could not afford an institutional delivery, and had to make snap decisions over whether they should sell their chickens to pay for a hospital delivery. The result is a steady increase in the number of mothers delivering at health facilities.5
Another Indian govenment initiative is supporting transport to the healthcare facility where a woman can receive the care she needs. There is now an ambulance service (nischay yan—‘ambulance is certain’) that is controlled centrally by the nearest government health administration.6 The emergency number is given to all women at their antenatal booking visit, as there is likely to be someone in their village who owns a mobile telephone.
Mobile telephone coverage and internet access have made it possible to develop telemedicine links globally, so that clinical expertise may be tapped and advice may be given instantly. Technology also gives the opportunity for networking with medical colleges, the ministry of health, donors, self-help groups and the primary health centre. In our facility we are considering the possibility of a ‘daycare’-type facility, with the option of inpatient care for the monitoring of high-risk patients, and a maternity home similar to that of the Tamil Nadu ‘birth resort’, where women can stay close to the institution while awaiting delivery.7
Indian society, and in particular rural society, still has a very high regard for the medical profession, so the medical fraternity has an opportunity to act as a catalyst, not only as a service provider but also to promote social justice.8 There is also the opportunity to educate communities and to guide them towards making beneficial health choices. Maternal death reviews, whereby information on all maternal deaths are collected and analysed, have now been introduced.9 Participating in these reviews provides an opportunity to learn where the deficiencies lie at each point in the delay model, so that steps may be taken to address them. At an individual institutional level, changes can be made: for example, our protocol for eclampsia now includes unconsciousness in bold letters as one of the presentations. Other suggestions for addressing the three delays that are also applicable in our setting are given in Box 1.
Table Box 1.. Suggestions for addressing the three delays applicable to our setting
|Increasing community awareness of risk in pregnancy and childhood through education and self-help groups|
|Political willpower, the establishment of social justice and an improvement in the status of women in society|
|Improvements in infrastructure, hospitals, roads and ambulances|
|Supply of free medicine to the poorest of the poor|
|Training and retention of more specialists and nurses, so as to enable the quick and efficient triaging of sick patients requiring life-saving emergency procedures|
|Life-saving skill and drills, and medical and paediatric early warning systems, to be developed and taught in medical schools and nurse training programmes at undergraduate level|
|Implementation of standardised countrywide protocols in every health facility, from the primary health centre to the medical college, with a sound referral system|
|Enforcing accountability in the medical and nursing profession|
|A government indemnity scheme to cover health professionals, so that they have the confidence to perform life-saving skills on mothers and children without fear of retribution from the families and communities when a patient dies|
Millennium goals are achievable, even in rural settings, but cases like these illustrate that it may take longer to meet these goals, and will need significant investment, as well as a better understanding of the target population’s needs and prior beliefs. We believe that it will be possible to achieve these goals with willpower, hard work and a real desire to understand and respect India’s rural women.
Disclosure of interests
None to declare.
Contribution to authorship
Both authors contributed equally to the design, drafting and critical appraisal of this article.
Details of ethics approval
Names have been changed in order to protect the identities of the patients described.