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By Rashme Sehgal Uttar Pradesh has a maternal mortality rate of 707 per 100,000. Activists believe that the poor quality of reproductive health services offered by state primary health centres, and the continuing target-based approach to family planning are responsible for this. Our correspondent discovered a trail of botched sterilisations, unsafe abortions, antiquated surgical techniques and hasty cover-ups
Lal Babu Singh, a former manager at Hindustan Steel Industry, Lucknow, rues the day his 27-year-old grand-daughter Sudha Singh stepped out of the house saying she was going to see a doctor as she had a stomach ache. On June 8, 2003, her dead body was brought back to Singh’s home. Sudha was not suffering from stomach ache, she was two months pregnant. Her brother’s wife took her to the Upper India Sugar Exchange Maternity Hospital in Kanpur where she was admitted for an MTP (medical termination of pregnancy). Tragically, the surgeon who did the MTP ended up damaging her intestines and ovaries. On June 1, Sudha underwent a second operation. She never regained consciousness. Singh has since retired and opened up a small property agency. Being strapped for cash he has made no attempt to get any kind of compensation for Sudha’s death. He says matter-of-factly: “Sudha died as a result of septicaemia. The hospital refused to accept any blame for her death and, every evening, would make her sign a register stating she was happy with the services she was receiving. I did speak to a few lawyers but I do not have the finances to pursue the case. As it is, I ended up spending Rs 12,000 for the 10 days she spent in hospital. Both Sudha’s children are being brought up by their grandparents in Samogar village in Deoria district.” Sheela from Taktapur village in Varanasi had four children within the span of six years. A local community-based disbursement worker told her that if she got herself sterilised she would ensure that her family received one acre of agricultural land. To Sheela and her mason husband Lallu Lal, this seemed like a huge incentive. They agreed to the operation. On November 29, 2002, Sheela and six women from the village were admitted to Din Dayal Hospital where a sterilisation camp was being organised. A short while later, Sheela was rushed to the Kabir Chaura district hospital where she succumbed to peritoneal shock and mesenteric over-stretch. In simple terms, the doctor pulled at the intestines and associated membranes so hard while conducting the tubectomy operation that Sheela went into shock and didn’t survive. It was only at the intervention of a local Varanasi NGO that the police agreed to file an FIR and give Rs 10,000 as compensation to Lallu. Sheela’s neighbour, Rani Devi, who accompanied her to the camp says: “Before she went into a coma the doctors took a thumb impression on a piece of paper which said that she was happy with the way the operation had been performed.” Mrida Kumari, mother of three children and resident of Kunwarpur village in Gonda district, was persuaded by the local ANM (auxiliary nurse midwife) Shakuntala Singh to undergo a sterilisation operation. On January 30, 2003, Mrida and her sister-in-law walked four kilometres to nearby Halgharmau where a sterilisation camp had been organised at the local primary health centre. Dr Alok Aggarwal, the surgeon, was allowing five minutes for each tubectomy and had already completed four cases in 20 minutes. Mrida’s turn came at 3.20 pm. Dr Aggarwal had just finished giving her two injections when Mrida said: “Mera dil ghabraraha ha (I am frightened).” That did not stop the doctor from making the incision. He was about to insert the trocar when he realised she was dead. Aggarwal described her death as a “hysterical heart attack”. There was no ambulance or even an oxygen cylinder at the centre. No effort was made to revive Mrida. Aggarwal immediately left the sterilisation camp to report the matter to the Gonda chief medical officer. Mrida’s sister rushed back to Kunwarpur to inform the family, that arrived at 5.30 pm to find the camp deserted and Mrida’s body lying on a blood-spattered stretcher outside the primary health centre. When questioned, Aggarwal said: “If we go by the standards laid down by the government we would not be able to conduct a single operation. We have to start operating once the women are brought to us otherwise it becomes difficult to get them to come back. Moreover, the ANMs keep telling us to hurry up as they want to meet all kinds of targets.” These are just three examples of lives that have been shattered because of the sub-standard level of medical care being given to women in the towns and villages of Uttar Pradesh. Uttar Pradesh has the highest maternal mortality figures in the country, according to the Indian government’s sample registration system. It also has the highest rate of abortions according to statistics compiled by the National Family Health Survey (NFHS) in 1998-99. In Uttar Pradesh, 40,000 pregnant women die every year. A maternal death audit conducted by the ministry of health and family planning showed that the maternal mortality rate in Uttar Pradesh was 707 per 100,000, whereas for the rest of India the figure was 404 per 100,000. The NFHS maintains that unsafe abortion is one of the most important reasons for maternal deaths. Other causes include bleeding, high blood pressure and obstructed labour. All these can be prevented with regular antenatal care, trained supervision during labour, appropriate referrals and proper post-delivery follow-up. Serious complications affecting women during pregnancy include night blindness, blurred vision, convulsions, swelling of different parts of the body, vaginal bleeding and anaemia. Dr Abhijit Dasgupta, member of the Lucknow-based NGO Sahyog, believes indifference on the part of both doctors and ANMs remains the main cause for maternal deaths. “Doctors, in order to save time, tend to give both the sedative and the local anaesthetic injection together. The patient is then made to wait for a couple of hours, by which time the effect of the anaesthesia has worn off and the woman is left shrieking with pain while she is being operated,” says Dasgupta. Kanpur-based Ganesh Pande, who has been running the NGO Shramik Bharti for the past 18 years, says: “What is going on in the name of health services is nothing short of butchery. The problem is compounded by the fact that the status of women here is so low that they dare not raise their voice against the medical community.” Leading freedom fighter and noted gynaecologist Dr Laxmi Sehgal, also Kanpur-based, blames the government for having completely abandoned the healthcare sector. “The result is that women’s health has deteriorated. Earlier, women at the grassroots level were being trained as dais. Unfortunately, all training programmes have come to a halt and health has become the main cause of rural indebtedness. Individuals are being forced to meet 83% of all health expenses, whereas the government is meeting only 17% of the individual’s health expenditure.” Yashodra Dasgupta of Sahyog agrees. “The government is trying to shirk its responsibility by holding these poor women responsible for not availing of the health facilities being provided to them. Our experience has shown that village women are very aware of the need for family planning. That is why they approach the primary health centre for assistance. The abysmally poor quality of services ends up causing death and disability to the very people who approach them.” “We have come across horrific cases where doctors were using bicycle pumps and blood pressure instruments to fill the abdomen with air for laparoscopic ligation. Instead of gradually releasing the air before removing the trocar, the surgeon would pull out the trocar immediately after the rings were in place. I have also seen one surgeon attend to 75 cases in two-and-a-half hours, giving an average time of two minutes to one case,” Yashodra adds. What is the government doing to change the situation? Rajendra Bhonwal, secretary, family welfare, in the Uttar Pradesh government, puts the blame on shortage of staff. “The UP state government has sanctioned a new scheme whereby we are no longer going to hire regular staff since the procedure is too long-winded. Rather, we are planning to induct a large number of private practitioners into the service by paying them Rs 1,000 per day. We are also going to increase the number of ANMs and PHCs at the village level. UP has 94,000 villages whereas the number of ANMs is only 23,000. Every ANM is being forced to look after at least four villages. Naturally there will be some pitfalls,” says Bhonwal. Bhonwal insists the Uttar Pradesh government is no longer shoving the ‘target approach’ at ANMs. “We believe women need to follow the spacing method instead of just going in for sterilisation,” he adds. Savita Mishra, an activist with Shramik Bharti, believes the situation on the ground is entirely different. “ANMs have been told that if they fail to achieve targets they will not receive their salaries. I know of cases where ANMS have not been paid for six months at a stretch.” The statistics speak for themselves. In 2002-2003, there were 469,120 sterilisations in the state of Uttar Pradesh, while in 2000-2001 the figure was 418,453, according to the Uttar Pradesh family health department. Dr Dasgupta says: “Our estimates show that 15,000 of these operations fail each year. We have raised this issue with several chief ministers but they refuse to acknowledge the extent of the problem.” Women activists in Uttar Pradesh have come together under a common banner -- the Puri Nagrik Pura Haq Campaign -- which presses for an end to all incentive and disincentive schemes. They also demand that the state and state-owned medical fraternity be held responsible for the problems caused to thousands of women. They are demanding that deaths and failed sterilisation operations be compensated on a case-by-case basis and that the state institute a Health and Family Welfare Commission to monitor cases on a monthly basis. (Rashme Sehgal is a senior journalist based in New Delhi) InfoChange News & Features, May 2004
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