Very sorry maternity care
As several women end up giving birth on roads, questions loom large on ethical and humanitarian values
The perception of childbirth at home and at public health institutions is very different among social groups and policymakers in the country. And, this is because India has, for decades, been pushing for institutional delivery through different policies and programmes, particularly Janani Suraksha Yojana.
While this could get the maternal mortality ratio down, India still stands way behind the Sustainable Development Goal for this. One big reason: More and more reports of obstetric violence, disrespect and abuse in labour rooms in public health institutions have surfaced. Abuse during childbirth is why people in lower socio-economic groups prefer home delivery.
According to National Family Health Survey (NFHS), those opting for home deliveries mostly belong to Scheduled Tribes (31.7 per cent), and Scheduled Castes (21.3 per cent) or have the lowest wealth index (40 per cent). Also, people in poor socio-economic groups prefer public hospitals for institutional deliveries over private ones. But this is because the poor have nowhere else to go. They can't afford private health care and at government hospitals, they are nothing more than a way to meet scheme targets.
The socialisation process of doctors at government medical colleges could have led to violence in labour rooms. A study done in Aligarh shows that 84.3 per cent of women faced at least a form of disrespect and abuse (DA), 10.2 per cent were either abandoned or neglected and 5.9 per cent faced physical abuse during institutional deliveries.
DA in labour rooms is not new, but a more nuanced concept of obstetric violence is under considerations by scholars after the Venezuelan government enacted it in a law. Terms like disrespect and abuse might not be broad enough to convey the dehumanising nature of healthcare practitioners in labour rooms.
In 2013, Varun Patel, a junior resident in a Delhi hospital, wrote about his year-long internship experience, which created waves among the medical fraternity. In his piece, he revealed the dark side of the medical practice in government hospitals. In the process of socialisation of interns in these hospitals, he writes, "Nobody wants the patient admitted in their own ward. They call it 'Batting', you would see them proudly blabbering around – 'Hey! Aaj Maine 6 Bat Kiye', meaning he got rid of six patients that day. Where do these patients go, you may wonder. They get admitted to the wrong department where they don't get proper treatment or else they are encouraged to go home, in spite of their vulnerable health."
Students at medical colleges also talk about a dreadful tradition of slapping women in labour rooms. According to an investigative article published on a news platform, they justify this by saying doctors lose their temper when women cry in the labour room.
Patel also said giving birth in government hospitals is not any less than third-degree torture in jails.
Obstetric violence, disrespect and abuse could be considered human rights violence, but it for sure is a public health concern. The worst form of obstetric violence is refusing to admit a patient in the hospital irrespective of how dire their circumstances are. Sometimes, such patients end of giving birth on roads.
Four such cases have already made headlines in just January 2019 and in two of them, the babies died right after birth. It was also reported that despite reaching primary or nearest health centres on time they were either referred to tertiary care or not entertained at all. In Chitradurga district of Karnataka, a pregnant woman was asked to come in later because the doctor was having his lunch. Consequently, she had to deliver the baby right outside the hospital.
Refusing to admit patients is one the major reasons behind undignified births. Such inhuman and forced deliveries are an alarming sign of lacunae in the healthcare system. In 2018, 19 such cases were reported by the media and in three of them, the babies died immediately after birth. Seven out of 19 cases happened because they were denied admission in the hospital and the reasons they gave were that the patients didn't have an Aadhaar card, a bank account, wasn't accompanied by an Asha worker, and that doctor was not on duty.
A comprehensive report on such incidents across the country is warranted for a better understanding of the complexities of giving birth on a road. While these figures have been drawn from news stories, mapping these could give a rough idea of the magnitude of the problem.
Nine of the 19 incidents occurred in Uttar Pradesh, mostly in the state's western part, two each in Madhya Pradesh and Andhra Pradesh and one each in Bihar, Rajasthan, Punjab, Haryana, Delhi and Uttarakhand. This map shows that most of the cases were reported in states adjacent to the capital and they reduce as one goes further away from Delhi. This implies that such incidents go unreported in remote areas and southern and northeastern states.
In a few cases, women were forced to deliver in a drain or above the garbage inside hospitals. In one such case that occurred in UP's Bijnor district, the pregnant woman was referred to Meerut Medical College as her husband didn't have Rs 4,000 to pay a bribe to the hospital staff. She gave birth while standing outside the hospital waiting for a bus. The baby died due to a head injury.
All of this raises a question over the right to dignified maternity care and on the medical fraternity's ethical and humanitarian values.
(The author is a research scholar at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi. The views expressed are strictly personal)