In a bid to promote safer deliveries in hospitals and arrest India’s high maternal mortality rate, has the National Rural Health Mission deliberately sidelined the country’s 1 million traditional midwives?

The National Rural Health Mission’s (NRHM) push to equate safe deliveries with institutional deliveries is not borne out by fact. Health experts attending a two-day consultation focused on redefining and expanding the role of dais in the institutional framework, which concluded on May 2, warned that the site of maternal deaths has shifted from the home to the hospital.

One of the chief reasons for this worsening situation, experts say, has been the NRHM’s deliberate attempts to sideline the 1 million dais who have long played a critical role in providing counselling and healthcare at the village level.

India enjoys the dubious distinction of having one of the highest maternal mortality rates (MMR) in the world. In the state of Uttar Pradesh alone, according to recent National Family Health Survey (NFHS) figures, 40,000 pregnant women die each year.

It was in a bid to arrest these deaths that the NRHM began focusing on institutional deliveries, offering every mother who delivered in a hospital Rs 1,700 under the Janani Suraksha Scheme (JSS).

The statistics released by the NRHM at the consultation are revealing. Dr Abhijit Das, member of the Lucknow-based NGO Sahyog, pointed out that 93% of all deliveries that took place in February 2008 at primary health centres (PHCs) in Andhra Pradesh were normal, with 83% of patients using referral transport provided by the nearest government facility.

A break-up of the statistics shows, however, that the number of nurses in the labour room at primary health centres in Andhra Pradesh was as low as 19%. The number of auxiliary nurse midwives (ANMs) trained as skilled birth attendants (SBAs) was only 35%.

Uttar Pradesh claimed that 99% of deliveries that took place at its PHCs were normal. Nevertheless, the number of trained SBAs present was a mere 4.5%, medical officers available at the PHCs 1.5%, trained nurses 3.8%, and ANMs 4.5%.

“With available trained staff being less than 15%, who is there to take care of the woman during her delivery,” asked Das.

Madhya Pradesh, Bihar, Chhattisgarh and Assam also claimed a large number of safe deliveries. But activist Prashant, who is with the Voluntary Health Association and has been working in Maheshwar block in Madhya Pradesh for the last three years, claims the picture is completely different on the ground.

“There are no doctors or nurses available at any of the PHCs that come under this block. Patients seldom receive medical care when they most need it,” he pointed out.

Babiben Parmar, president of the Dai Sangathan, Gujarat, felt that the traditional services provided by dais should not be overlooked. Rather, there was a need to redefine and expand their role as caregivers and health promoters beyond childbirth.

“Dais provide day and night care in our villages. Apart from support during childbirth, we promote immunisation, help prevent TB, HIV/AIDS, and even promote health insurance.”

Narmadabai, from Chittorgarh in Rajasthan, strongly advocated the need to see dais as playing a complementary rather than an adversarial role in the existing health machinery.

Bija, a dai from Jharkhand, spoke about how dais had learned to recognise the danger signs during pregnancy and have helped rush women to the nearest referral service. “A woman was facing life-threatening complications whilst undergoing her third delivery. Since Jharkhand did not have a hospital where a caesarean section could be performed, I took her to the adjoining state of West Bengal where such a facility was available. When the woman went into labour and a doctor could not be found, I ran around till such time as a doctor could be arranged,” said Bija.

Mirai Chatteree from SEWA, Ahmedabad, pointed out that at present Tamil Nadu and Kerala were the only states where almost 100% institutional deliveries are taking place.

There was some discussion at the conference about creating a standardised curriculum for dais; however it would be difficult to impose such a curriculum throughout the country.

Participants pointed out that 26 million deliveries take place every year in India. “Do we have enough institutions and adequate infrastructure and trained personnel to deal with such a large number of cases,” asked activists.

Manisha Malhotra from the Ministry of Health and Family Welfare concluded: “The NRHM has not disowned dais. In fact, the NRHM is considering guidelines to provide them with financial incentives.”

-- Rashme Sehgal