by Dr. Sandhya (Director, Research and Project mMitra)
( Dr. Sandhya had this particular experience while she was conducting qualitative research for the mMitra/DFID project. This is an anecdote from her field visits).
Nirmala (19) in Kati village had registered her pregnancy at the village sub-centre (first contact point of government health service) as well as at a private hospital. I wondered what could be the reasons behind her dual registration? Key informants of the health system enlightened me saying that “This happens in case of a few of primi para (a woman who is pregnant for the first time) cases. As per local culture norms, the primi para patient is brought to her maternal home for delivery. Her parents are responsible for all the care and expenses involved…. Parents who are relatively well placed, opt for private hospital as compared to a government facility because the former is known to offer a better quality of service…..The reason Nirmala was registered at a sub centre could be that it was located within her village whereas the private hospital was 7-8 kilo meters away…..When the labor pains start in the late night hours, it becomes difficult to arrange auto rickshaw or taxi to transport the patient to private hospital. In order to cater for such emergencies, parents invariably register their daughter at the government sub-centre also……This was perhaps the reason that Nirmala received ante natal care at the private hospital but for her delivery she turned up at the sub-centre in the middle of the night”.
The sub-centre’s auxiliary nurse midwife (ANM) used to reside in her government accommodation adjacent to the centre. The ANM, a warm and committed person immediately admitted Nirmala into the labor room. The delivery was normal and Nirmala and the baby were kept under observation for 48 hours and then sent home. All was apparently well until then.
Next day, the infant fell sick and started crying non-stop. The family then sought consultation from the private hospital where Nirmala had received ante natal care. The infant had contracted jaundice and the doctors were not surprised at all! Nirmala had an Rh negative (a type of blood group) status and the private doctor had explained to her and her care giver that her infant was required to be given an injection within 23 hours of delivery to prevent neo natal jaundice. Nirmala’s Rh negative status was not shared with the ANM by the family and so no action was taken by her. I did ask the ANM as to what action is usually taken at the sub-centre in similar cases? I was told that she would have arranged a transport under EmOC (government’s emergency obstetric care services) and sent the patient and new-born to a primary health centre for the required injection and further treatment. To my question on ANM’s guess as to why the family did not share Nirmala’s Rh negative status with her, she said that “It may be because she had registered at my sub-centre but was not regular in her ante natal visits and the family felt guilty of the same…..May be they feared that I may turn them away….Not that I would have”. ANM continued to say “As usual, I had asked for case papers from the private hospital but they didn’t show me….Unfortunately, the infant developed neo natal jaundice……There was delay in the family seeking proper care……and the infant died.”
This was a preventable neo natal death because the risk factor was known and explained to the concerned family. The family had been taking good care of Nirmala by taking her to a private hospital for consultation but at the eleventh hour made an erroneous decision more due to infra structural barriers in the environment. Had the family been able access public or private transport when Nirmala went into labor, it is highly probable that the baby would have survived.