Written by Dr. Aparna Hegde
Kiran, a 24 year old young woman living in one of the slums of Mumbai, attended the antenatal clinic of a peripheral municipal hospital in the fourth month of pregnancy for regular antenatal care. However due to the long queue of patients waiting outside the outpatient department, the nurse could do no more than cursorily examine her and ask her to come back for her next visit. Kiran never went back for antenatal care. And in the eight month of pregnancy, she was brought, bleeding profusely and dying, in the dead of night, to the tertiary care centre where I was the third year registrar. She had developed pregnancy induced hypertension in her fifth month of pregnancy that had not been diagnosed and in the eighth month, she developed abruption (her placenta separated without warning from its attachment to the uterus). Kiran valiantly fought for her life but we lost her despite our best efforts. Kiran’s death always stays with me. Not just because she suffered through a very tragic death but also because we could have prevented it. Kiran had approached the health care system for care during pregnancy. But we failed her. We did not counsel her about the need for antenatal care, the danger signs of pregnancy, the potential complications and the need to come back for antenatal and infancy care.
Though there has been a 10% fall in the maternal death rate in India since 2007-2009, it is still 179 deaths per 100,000 live births. (1). A woman dies in childbirth every eight minutes (1). India accounts for more than 17% of maternal deaths in the world every year (1). While the situation in rural India is grim, unfortunately urban India does not offer any respite. Urban slums are deprived human settlements, which are demographically, among the poorest and most under-served groups in terms of health (2). There has also been an urbanization of poverty with almost one out of four poor persons now living in urban slums (3). Available indicators for the urban poor compare unfavourably with both urban and national averages. In vulnerable situations, women and children are often the most vulnerable. The infant mortality rate for urban infants with low standard of living index is 76.1 and the neonatal mortality rate is 48.8 per thousand (compared with national figures of 67.6 and 43.4 per thousand) (4). Low birth weight prevalence in urban slum communities is as high as 56% (5) as compared to a rural incidence of 38.1% and an all-India prevalence of around 33% (6, 7). According to National Family Health Survey- 3 (8), in Mumbai, Delhi and Meerut, only 36-39% of poor women used any modern method of family planning (8). Only 29% of women in Mumbai consumed iron and folic acid (IFA) tablets during their pregnancy for at least 90 days (8). All indicators of delivery and postnatal care were consistently better in non-slum areas when compared to slum areas in most Indian cities in NFHS-3 (8). Almost 45% of children under age five in Mumbai and 41% in Delhi were found to be stunted in the NFHS-3 indicating that they had been undernourished for some time (8).
One contributing factor to this distressing situation is the absence of preventive information available to underprivileged women in urban India.
The reach and effectiveness of maternal and child health services in urban slums are compromised due to a complex and interrelated web of causative factors. These include (3):
- Systemic factors:
- lack of organized public sector infrastructure and services in many urban areas especially tier 2 cities
- poor referral system leading to overburdening of the tertiary centres while the community level primary health centres are underutilized
- higher allocation for bigger cities to the detriment of tier 2 cities
- poor access and utilization of services despite proximity due to poor demand, minimal outreach services, weak community-provider linkages etc
- perceived apathy on the part of the health care providers
- Urban poverty related factors: Large proportions of slums are invisible. Illegality of slums and social exclusion has led to extremely poor health care provision for the hidden and missing pockets of urban poor that are not part of official slum lists. The weak social fabric due to constant threat of eviction and migration leads to reduction in the collective negotiating capacity.
- Weak coordination among and limited capacity of the various stakeholders for preventive care: There are various private and government entities providing health care that operate in isolation with little coordination. The focus of almost all stakeholders is on curative care with very little effort expended on provision of preventive care.
- Inadequate political and civil society consciousness with greater rural bias.
Due to thesestifling systemic factors, especially overcrowding of government hospitals, there is very little counselling offered to pregnant women, even when they have the recommended number of antenatal visits. The quality of information given to pregnant women even when there is uptake of antenatal care is also problematic. In a study at a tertiary hospital in Pondicherry, 79% of the 108 surveyed primigravida women who had a minimum of three antenatal visits had received no antenatal counselling about breastfeeding (9). According to a study in Delhi slums, only 13% of newborn infants with symptoms requiring hospitalization were appropriately advised at the primary health center to visit a secondary or tertiary facility (10).
The value of appropriate antenatal and postnatal care cannot be overemphasized. Women who do receive appropriate antenatal care are almost 4 times more likely to deliver with a trained birth attendant, and almost 3 times as likely to deliver in a health care facility, than women who do not receive antenatal care (11) reducing their risk of mortality. Maternal education and antenatal care are not only important in reducing maternal mortality, but also in reducing infant and under five mortality (U5M) (12). Having either antenatal care or skilled delivery care can reduce U5M by 6%, and having both antenatal and skilled delivery care can further reduce U5M by another 3% (13). Jones et al. of UNICEF India identified the child survival interventions of proven impact, feasible for use at high coverage in India and calculated their effect on child mortality if high coverage was achieved (14). They found that exclusive breast feeding, oral rehydration therapy and adequate complementary feeding were among the most effective interventions and if they were to be applied universally, 57% of mortality among pre-schoolers could be prevented (14). However lack of counselling leads to limited acceptance of these best practices (14).
In rural India, there is a trained cadre of community health workers, Accredited Social Health Activists (ASHA) who are responsible for health information dissemination. However in urban India, such a cadre does not exist. Also the economic pressures in the slums are such that anyone who can work, is employed, making it difficult to get a purely voluntary worker in urban slums (15). The focus on curative services in urban India has also meant that the primary preventive health care approach is given short shrift.
- United Nations 2014. The Millennium Development Goals Report 2014.
- World Bank (2002). Report of a consultation on the health of the poor in urban India. New Delhi: World Bank.
- Agarwal S and Sangar K (2005) Need for dedicated focus on urban health within national rural health mission. Indian Journal of Public Health XXXXIX (3): 1-10.
- City Initiative for Newborn Health_Overview and Protocol Document (2006), SNEHA, India.
- Sachdev H (2001) Low birth weight in South Asia. INt J Diabetes Developing Countries; 21(1).
- ICMR (1991) ICMR Task Force National Collaborative Study. New Delhi: Indian Council for Medical Research
- UNICEF (2000)The state of the world’s children. New York: United Nations Children’s Fund.
- National Family Health Survey III. Government of India. 2006. http://www.nfhsindia.org/NFHS– 3%20Data/VOL-1/Summary%20of%20Findings%20%286868K%29.pdf
- Dandapany G, Bethou A, Arunagirinathan A, Ananthakrishnan S (2008) Antenatal counselling on breastfeeding—is it adequate? A descriptive study from Pondicherry, India. International Breastfeeding Journal; 3:5
- Bhandari N, Bahl R, Taneja S, Martines J, Bhan M (2002) Pathways to infant mortality in urbanslums of Delhi, India: implications for improving the quality of community- and hospitalbasedprogrammes. J Health PopulNutr; 20: 148 – 55.
- Bloom et al. (1999) Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning. 14(1): 38-48.
- Facilitators’ Guide for conducting training for ANMs, LHVs and staff nurses as a skilled birth attendant (2006) Maternal Health Division. Department of Family Welfare. Ministry of Health and Family Welfare. Government of India.
- Claeson et al. (2000) Reducing child mortality in India in the new millennium. Bulletin of the World Health Organization. 78: 1192-1199.
- Jones G, Schultink W, Babille M (2006) Child Survival in India. Indian J Pediatr73 (6): 479-487.
- Pardeshi G, Kakrani V (2006) Challenges and options for the delivery of primary health care in disadvantaged urban areas. Indian Journal of Community Medicine 31(3): 132-136.