Last year, Kamla, 28, a poor farmer in Rajasthan's Dholpur district, was flabbergasted to see her eight-month-old fetus pop out of her uterus as she toiled in a field. Bleeding profusely, the hapless woman fainted on the spot. Thankfully, Kamla's co-worker, Sunehri, kept her wits about her and rushed to a phone booth to contact a local obstetric helpline. Within minutes, a van taxied in to ferry Kamla to a local hospital where she safely delivered a baby boy.
For scores of mothers-to-be like Kamla, the Janani Suraksha Obstetric Helplines - set up across 28 districts in Rajasthan under the Central government's Janani Suraksha Yojana (JSY) scheme launched in 2005 - are proving to be a blessing. A pan-India, safe motherhood intervention project under the National Rural Health Mission (NRHM), JSY aims to whittle down maternal and neo-natal mortality by promoting institutional delivery among poor women. Overall, the project hopes to ensure that the Maternal Mortality Rate (MMR - number of deaths per 100,000 live births in a year) declines from 400-plus to 100 and the Infant Mortality Rate (the number of deaths per 1,000 live births) from 55 to 40.
Rajasthan's 28, 24-hour helplines, which were set up in 2006 are also supported by UNICEF. Apart from assisting pregnant women with early registration at a local health centre, the helpline workers also take charge of antenatal and postnatal care and arrange for transport to the health centre at the time of delivery. In case a woman reaches on her own to the first referral unit, re- imbursement of transportation expenditure is made under JSY. And if she is not registered under the scheme as a beneficiary, payment is made for transport by the helpline staff. UNICEF inputs under the scheme include technical support, funding to train resource persons and grassroots functionaries, conducting sensitization workshops to familiarize communities with the helpline system (especially its emergency phone number), workshops with private vehicle operators and the infrastructure cost.
The JSY helpline system works seamlessly. Once the emergency call is received, the staff immediately contacts a registered taxi, which picks up and ferries the pregnant woman to the nearest health centre. At the centre, the helpline staff coordinates the patient's admission and hospital stay.
The initiative works on a simple system of mobile connectivity. Currently, 28 NGOs in Rajasthan have been tapped to operate in select blocks in as many districts. About half-a-dozen field workers in every block have been given a mobile phone each. The helpline numbers have been provided by Bharat Sanchar Nigam Limited along with 178 mobile handsets for workers under the project.
One of the most important positive outcomes of this programme has been that all across Rajasthan - the first state in the country to boast of such helplines - the well-being of the mother/newborn is increasingly becoming a close-knit community affair. As the JSY helpline focuses on a strong referral service for women with obstetric emergencies, all vehicles (state or private?) in the covered villages/blocks are identified and registered. In cases of emergencies - when pregnant women need to be rushed to health centers - the referral service is made available immediately. A strong network is also built among the vehicle owners, people with access to telephones and cell phones. This ensures that the doctors/medical staff is present at the local medical centre when the pregnant woman arrives. Much emphasis is laid on the involvement/support of the local people to make the project a success. Says an NRHM official, "From being just a pregnant woman's responsibility, childbirth has now assumed the importance of a community exercise, where everybody pitches in to ensure the well-being of the mother and the newborn. This is a very healthy sociological development."
Indeed JSY's helpline hasn't come a day too soon considering India accounts for a sizeable 20 per cent of the world's maternal mortality cases, according to UNICEF. Worse, in Rajasthan, low literacy, poor infrastructure and poverty ratchet up this ratio to an alarming 445 per 100,000 births - one of the highest in the world.
According to the UN, more women in India die during pregnancy and childbirth than in any other country in the world. India's MMR is thus disquieting with one pregnant woman dying every five minutes. According Paul Hunt, a human rights expert with the UN, who was in India recently, India's MMR is "shocking" for a middle-income country. Hunt stated that the Indian MMR is six times that of China's, 14 times that of Chile's and eight times worse than even Cuba's, a country, which has been witnessing political upheaval for the past few years.
"Most of the maternal deaths in India are avoidable as they are caused by poor nutrition, abysmal antenatal care, home births which trigger delivery complications and poor access to health clinics," says a health project officer for UNICEF in Rajasthan. Poverty, poor transport and health infrastructure force over 70 per cent of the women in the state to deliver at home which could result in maternal deaths due to hemorrhage, eclampsia, infections, obstructed labor, abortion and anemia. "Due to insufficient health information, the poor often think that if a pregnant woman has pain or bleeding, it is part and parcel of a normal delivery," says the health officer. "This misinformation often reduces mothers-to-be to a 'maternal death' statistic."
The World Health Organization (WHO) defines "maternal death" as "death of women while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by pregnancy or its management." While there are various reasons for India's high MMR, including early marriage and childbirth, lack of adequate health care facilities, inadequate nutrition and absence of skilled personnel worsen the situation. The level of maternal mortality is an indicator of the socio-economic growth and the health conditions of a society.
Though official figures of the JSY's helpline scheme's efficacy are yet to be tabulated, there's no denying that the intervention programme has altered the community dynamics in Rajasthan by focusing more on the health of pregnant women and newborn children. Consequently, it has also improved pregnancy outcomes through institutionalized deliveries.