Few ambulances, overburdened doctors among hurdles tribal women of Maharashtra"s Palghar face in accessing maternity care

  • Distance and access to the nearest health facility has always been a challenge for women in tribal hamlets

  • It only aggravates the problems if the family is poor and cannot afford to hire vehicles to ply long distances

  • The doctors and hospital staff in tribal districts are overburdened, lacking adequate human and technical resources

Though Suvarna Ghurav from Satkor village in Palghar district, then eight months pregnant on 29 August, survived the trauma of antepartum bleeding, she lost her baby due to delay in receiving timely treatment. On that fateful afternoon, the Ghurav family was in a state of panic when they saw 23-year-old Suvarna, then in her last trimester, in a pool of blood.

She was bleeding excessively from the birth canal: a complication called antepartum bleeding. Almost an hour was lost in consulting their bhagat (traditional healer), calling their local Accredited Social Health Activist (ASHA) worker Sujata Nadage and dialling 108 or 102 ambulance service, which remained unavailable.

After much hassle, Nadage and Suvana's husband Amit, her father, traditional birth attendant and mother-in-law, managed to hire a vehicle and took a pale Suvarna to the Taluka Rural Hospital (RH) in Vikramgad, 10 kilometres from the tribal hamlet of Navapada where the Ghurav family resides.

When the doctors examined Suvarna, they were unable to hear the baby’s heartbeat. Lying partly unconscious on a hospital bed, Suvarna had no idea she had lost her baby. Examining the incessant vaginal bleeding and its complications, the doctors referred Suvarna’s case to Jawhar Sub-District Hospital, 27 kilometres from Vikramgad Rural Hospital . This referral was made because the RH is not equipped to handle pregnancy-related complications and C-sections.

 Few ambulances, overburdened doctors among hurdles tribal women of Maharashtras Palghar face in accessing maternity care

Amit Ghurav, his wife Survana and ASHA worker Sujata Nadage near her home in Navapada_Satkor, Palghar District. Image courtesty: Shraddha Ghatge

Suvarna’s family and Nadage reached Jawhar Sub-District Hospital (SDH) at 5.15 pm in an ambulance provided by the rural hospital. However, there was little respite. According to Nadage, when they reached the SDH, the staff nurses were angry at her and Suvarna’s family for not having brought her to the hospital earler.

A nurse said Suvarna's pregnancy was high risk; she already had a low haemoglobin count (7.1) as opposed to the required range for pregnant women or lactating mothers (11.5-15.5) and could have lost a lot of blood even after the delivery. “We (hospital staff) were short on equipment and resources necessary to tackle further complications. Besides, the sole gynaecologist who looks after such complicated deliveries was unavailable. They should have first called to check if the doctor was available, which could have saved time. We referred Suvarna to Nashik Civil Hospital to avoid further delay,” she added.

Travelling another 75 kilometres, they reached Nashik Civil Hospital around 8.00 pm.

Nagade recalls: “It is a miracle that Suvarna survived. When we reached Nashik Hospital, the doctors and the nurses were also angry at us for this massive delay. They, however, treated Suvarna who, under induced labour, gave birth to a 2.2 kilogram still-born child. She lost a lot of blood even after the delivery, but she was taken care of. However, the staff was extremely rude and not at all cooperative. Suvarna’s dai (traditional birth attendant) and I had to even clean up chunks of blood clots during the delivery. Since there was no space to cremate the child nearby, Amit and her father took the body in a plastic bag to the local police station and got a punchnama. They later buried the body in a pit near Panchavati River.”

Suvarna was kept under observation for three days. Her family and Nadage stayed by her side until her condition stabilised. However, the family’s journey home wasn’t easy. An anaemic Suvarna — still reeling from blood loss — and her family had to board a bus from Nashik to Jawhar, then switch to another bus from Jawhar to Uprale and finally hire an auto from Uprale to Satkor village where they live. Had the ambulance service worked and the Vikramgad RH been equipped to treat her complication on time, Suvarna’s baby might have survived.

When asked about the non-functional Operation Theatre (OT) of the Vikramgad RH for conducting complicated and C-sections, its on-call medical officer, who did not wish to be named, said the Vikramgad Rural Hospital is only equipped to handle normal deliveries (around 100 per month). “In case of complications or C-sections, we refer the patient to the Jawhar Sub-district Hospital since our OT has been non-functional for many years. The post-mortem is usually done in the adjacent room to the OT which is why we have not been able to secure negative swab test report which is mandatory for compliance,” he said.

Distance and access to the nearest health facility has always been a challenge for women in tribal hamlets. It only aggravates the problems if the family — like in most cases — is poor and cannot afford to hire vehicles to ply long distances. According to a doctor at Vikramgad RH, “Although 108 emergency services are plying in rural areas, their frequency seems to have reduced a lot.”

Recalling the inconvenience caused due to unavailability of 108 ambulances, Urmila Patil, an ASHA worker from Deharje village in Vikramgad Taluka, said, “In July, Jyoti, a 21-year-old pregnant woman gave birth to her child in a private tempo while we were on the way to Vikramgad Rural Hospital, which is about 8.5 kilometres from Deharje. Her family and I tried calling 108 and 102 several times, but the call didn’t connect. Waiting was not an option, so we arranged for a private vehicle. We lost almost 40 crucial minutes. After a couple of kilometres, Jyoti began crowning and we decided to stop the vehicle. Thankfully, Jyoti’s dai (traditional birth attendant) was present, so the delivery occurred safely. We then rushed to the rural hospital so that mother and child got immediate medical attention. It would have been very difficult had there been any complications.”

“The call never connects,” said Parvati Khutade, an ASHA worker with Krunze Primary Health Centre. “Emergency ambulance services, which need to be prompt and easily available, are very difficult to avail. We never encountered such problems when the service was launched a couple of years ago. However, for more than six months now, getting an ambulance by making just one call has become an arduous task. We are usually told we will have to wait for almost an hour before the ambulance reaches our location since it is on another trip. We are left with no option but to hire a private vehicle,” she adds.

On lack of availability of 108 ambulances, a staff nurse with Vikramgad Rural Hospital, speaking on condition of anonymity, said that apart from the hospital’s own ambulance, every Taluka rural hospital has one 108 ambulance and one doctor assigned to it. “Since there is only one doctor, the ambulance is run either during the day or at night. Mostly, it is run during the night for emergencies. Most of them are booked for longer distances and when they get a call for a location somewhere in the interiors, they are unable to get there.” she said.

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A seemingly hesitant 108 ambulance driver sitting near the rural hospital entrance said, “It’s practically impossible to attend all the calls since the locations, usually, are remote. There is also hardly any cell phone network and roads are in bad shape, especially during monsoons when bridges collapse or rivers overflow.”

Nadage, who deals with several such emergency deliveries, even at wee hours of the night, said that they always face a problem when it comes to the availability of these ambulances. “Firstly, there is network problem in rural areas. Secondly, these days most of the drivers don’t tend to drive in extremely remote areas where there is actual need. Previously they used to promptly attend such calls, but now they don’t even answer them. Most of the times, we (ASHA workers) have to pay from our own pocket to hire private vehicle or auto in such emergency cases when ambulances are not available because the families we look after fall under below poverty line (BPL) category and can’t afford to travel,” she said.

Living in a small semi-pucca house they managed to build through Indira Awas Yojana, the Ghurav family thrives on a meagre income they gain from their one-acre paddy field. While Suvarna and her parents-in-law work in the field and take care of the family, Amit, Suvarna’s 29-year-old husband, undertakes odd jobs as a labourer or goes for fishing after rainy season to supplement the income.

“It was an unexpected incident because Suvarna had a normal delivery during our first child, Arnav, who is now three. We were extremely worried for both: the baby and Suvarna. It gets difficult in such situations when finances are tight, but we are just glad that at least Suvarna survived,” said Amit.

Even as Suvarna is gradually recovering now, her haemoglobin count is still low. A shy and introverted Suvarna, was not willing to talk about the incident. However, when asked if they would plan for another baby, she looked at her husband Amit and they both nodded with an approving smile.

“Not so soon. Wait for a few years,” Nadage promptly instructed her.

 

In a similar instance, Nadage had to escort 21-year-old Manisha Salkar from a hilly area of Halkaripada in Dadade village to Vikramgad RH as she her contractions began on the midnight of 5 September. Again, with no availability of 108 or 102 ambulance, they hired a private vehicle from the nearest pada (hamlet). When they reached Vikramgad RH, the on-call doctor referred Manisha’s case to Jawhar SDH since she needed a C-section. They reached the SDH at 3 am when the only doctor, who can perform C-section surgeries, was about to wrap up and leave the facility.

Manisha Salkar with ASHA worker Sujata Nadage at her home in Halkaripada, Dadade village, Palghar. Image courtesy: Shraddha Ghatge

Manisha Salkar with ASHA worker Sujata Nadage at her home in Halkaripada, Dadade village, Palghar. Image courtesy: Shraddha Ghatge

“I was lucky to have reached SDH on time. Had there been a little more delay, we would have been told to go to Nashik Civil Hospital,” said Manisha who gave birth to a 2.1kg baby girl. Sandeep, Manisha’s 27-year-old husband who does odd jobs on construction site, was quite stressed as it was their first child after 3 years of their marriage. “It was difficult to arrange for a vehicle in the middle of the night. Besides, we were worried if we would be able to get a doctor for her C-section surgery. But thankfully, everything worked out alright.”

The doctors and hospital staff in tribal districts are overburdened, lacking adequate human and technical resources. For instance, Jawhar SDH, which has 100 beds, gets patients referred to it from 11 Primary Health Centres of Vikramgad, Jawhar and Mokhada Talukas: up to 200 patients are sometimes admitted

The doctors have to treat 500 patients (200-250 children) every day. Besides, there are over 150 deliveries, including 10 to 12 C-sections, per month. Although there is a team of doctors present, there is only one anaesthesiologist and one gynaecologist working for the SDH. Thus, in case of complicated and emergency deliveries, if these doctors are unavailable, like in Suvarna Ghurav’s case, the hospital staff tends to refer the patients to the facilities which are equipped to deal with complications.

Talking about Ghurav’s case, a senior doctor in Jawhar SDH, speaking on condition of anonymity, said, “Anaemic mothers suffering from antepartum haemorrhage (excessive vaginal bleeding before delivery) is considered as a critical emergency case as it leads to almost over one litre of blood loss. Such surgeries need Intensive Care Unit back-up and transfusion of specific blood components. It’s very risky to treat such patients, as we can be held responsible if their treatment is not done prope rly without mandatory back-up. Hence, in such cases they are referred to Nashik Civil Hospital which has such facilities.”

Establishing new medical facilities would help unburden the patient inflow of such hospitals and also ensure good service. Every district has one civil hospital and there have been talks to set up a civil hospital in Palghar since the district was newly formed in 2014. “A civil hospital in Palghar and a 200-bed trauma care centre in Manor may soon be set up. We try our best to treat all our patients even with limited facilities. Once the medical facilities with good technical and human resource are established, it would resolve most of our problems,” he said.

The article is written under the Public Health Fellowship sponsored by Thakur Family Foundation

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Updated Date: Oct 15, 2019 14:55:54 IST