Fact-Finding Report on Maternal Health in the Ghaziabad Government Health Sector Thursday 9th August, Saturday 11th August, Tuesday 14th August Table of Contents: Introduction Relevant Constitutional Protections and Government Schemes Data from The Fact-Finding Main Areas of Concern and Suggested Improvements Introduction: Inadequate maternal health care is a serious problem throughout India. Indicators such as the maternal mortality rate (MMR), infant mortality rate (IMR), malnutrition, limited access to contraception, low levels of safe institutional delivery and the unavailability of adequate healthcare all contribute to poor maternal health. Government data from 2004 – 2006 and 2007 – 2009 shows that Uttar Pradesh in particular has consistently had the second worst MMR in India.1 The current MMR is 212 deaths per 100,000 live births; the country’s millennium development goal is 109 per 100,000 live births by 2015. 2 The MMR is measured using the number of women aged 14-59 who die from pregnancy related causes out of every 100,000 live births. Uttar Pradesh has a comparatively low percentage of institutional deliveries (22%) 1 http://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR_release_070711.pdf 2 http://zeenews.india.com/news/health/exclusive/a-maternal-death-every-10-mins-in-india-un_17710.html compared to the Indian average of 41% and Kerala and Goa’s 100% and 93% respectively3, thus 78% of women are delivering outside hospitals in Uttar Pradesh. Uttar Pradesh’s IMR is equally high compared to the rest of India. According to an India Current Affairs Survey, Uttar Pradesh had the second worst IMR with scores of 53 (2006), 51(2007) and 49 (2008) compared to Kerala’s scores of 12, 10 and 10 respectively4. The IMR is measured using the number of children under one year who die per 100,000 children. The current IMR is 50 deaths per 100,000 and the millennium development goal for India’s IMR is 28 per 100,000. The Ministry of Women and Child Development (MWCD) and World Bank formed a mapping study and created a “worst 200” list for districts in India regarding malnutrition. The researchers used the haemoglobin level of pregnant women and the weight/age ratio of children as their parameters for measuring malnutrition. Uttar Pradesh had 11 more high risk districts than any other state in India5. Inadequate access to quality, acceptable health care perpetuates these high levels of maternal mortality, infant mortality, and malnourishment. Ghaziabad District in particular is renowned for poor hospital conditions and substandard maternal healthcare. As of 2011 it is the third most populous district of Uttar Pradesh (out of 71), after Allahabad and Moradabad6. The district has a population density of 3,967 inhabitants per square kilometre (10,270 /sq mi)7. In addition to a large population, Ghaziabad District also has a high IMR and under five mortality rate. The IMR is 53, which is high compared to other districts, for example, the Jhansi district, which has an IMR of 42. The time trend of infant mortality showed that the infant mortality rate is likely to be 46 per 1,000 live births for the year 2015. However, the goal is to bring down the IMR to below 27 for the year 2015 under the MDG8. Ghaziabad’s under five mortality rate is also high at 66. This is the probability (expressed as a rate per 1,000 births) of a 3 www.nfhsindia.org 4 http://indiacurrentaffairs.org/infant-mortality-rate-in-india/) 5 http://wcd.nic.in/icds-worldbank/TOOLBOOK.pdf 6 "District Census 2011". Census2011.co.in. 2011. Retrieved 2011-09-30. 7 "District Census 2011". Census2011.co.in. 2011. Retrieved 2011-09-30. 8 http://www.iipsindia.org/pdf/a08mohanty_report.pdf child born in a specified year dying before reaching the age of five9. Clearly the government health system in Ghaziabad District is not providing adequate healthcare for the population. HRLN therefore sent a fact-finding team to investigate the maternal health problems in the government health sector in Ghaziabad District. From what the fact-finding team could discover, Ghaziabad has 2 District Hospitals called MMG (Jassipura, Naya Ganj, Ghaziabad) and Sanjay Nagar (Sector 23, H Block) both of which are located in the city of Ghaziabad itself. The District also has four Primary Health Centres (PHCs) but despite extensive searching the fact-finding team could only discover the locations of two of them in Loni and Dasna. The fact-finding team found the location of the seven Community Health Centres (CHCs) however which are in Mohanagar, Dasua, Garh, Hapur, Muradnagar, Modinagar etc. There are also nine Health Posts including Sashtrinagar Karte, Nandgram, Vinjay Nagal, Shahibabad, St. Mary School, Dabur, Sanjay Nagar and Hapar Chugnee. However, this information was very hard to find. The fact-finding team were solely dependent on directions from people that worked in the public health sector as the only addresses readily available on the internet are those of MMG and Sanjay Nagar. The fact-finding team wanted to visit a wide range of government facilities to get a complete picture of the maternal healthcare available in Ghaziabad. We visited the two District Hospitals, MMG and Sanjay Nagar, Loni PHC, Dasna CHC, Murad Nagar CHC, Modi Nagar CHC and two health posts, Sanjay Nagar and Dabur. Ultimately, the team found that problems like the maternal and infant mortality and malnutrition are extensive in Ghaziabad because of a multitude of flaws in the corrupt government health system. For example, in just three days, the team observed major issues including lack of electricity, poor and sparse contraceptive advice and procedures, inadequate ante- and post-natal care, wide disregard for sanitation, unavailable transportation and non-reception of government cash incentives. 9 http://mdgs.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=561 Relevant Constitutional Protections and Government Schemes: Article 21 of the Constitution of India guarantees a right to life. The Supreme Court of India has interpreted Article 21 to include the right to adequate medical facilities for preserving human life (Paschim Banga Khet Mazdoor Samity & Ors. v State of West Bengal & Anr, AIR 1996 SC 2426). In this case, the Supreme Court ruled that: (a) Article 14 – Equity before the Law: The state shall not deny to any person equality before the Law or the equal protection before the Law within the territory of India. (b) Article 15- Prohibition of Discrimination on grounds of religion race caste, sex, place of birth or any of them. : Nothing in this Article shall prevent the state for making any special provision for women and children. International law also includes protections for the right to health. The Convention on the Rights of Child, the International Covenant on Economic, Social and Cultural Rights (ICESCR), the International Convention of Civil and Political Rights (ICCPR), and the Convention for the Elimination of all forms of Discrimination Against Women obligate the Government of India to ensure accessible, acceptable, adequate, quality health care to all women and children. The Government of India has introduced various schemes to improve health care. For example, the Integrated Child Development Scheme (ICDS) provides three essential services for children from age 0 – 6: immunization, health check-ups, and referral. The Government provides these services through Health Sub Centres, PHCs and CHCs under the direction of the Ministry of Health & Family Welfare. The Government has implemented a three-tier set up for delivering health services to the Indian population. The first point of contact is a sub-centre, followed by a Primary Health Centre (PHC), and finally a Community Health Centre (CHC). According to the Indian Public Health Standards (IPHS) for Sub-centres, the success of any nationwide program especially related to public health would depend largely on well functioning, acceptable sub- centres, as sub-centres are the first contact point with the community. Sub-centres are designed to provide promotional, preventative, and limited curative services to the immediate community. As per population norms, each Sub-centre should serve a population of 3,000 to 5,000 people. Each sub-centre will have a referral PHC that will provide care for a total population of 20,000 to 30,000 people. Finally, several PHCs will feed into a CHC that will cover 80,000 to 1,20,000 people. IPHS have provided the minimum requirements (Assured Services) that the Sub-centre should provide: 15.1 Maternal and Child Health: Antenatal care: Early registration of all pregnancies, ideally within first trimester (before 12th week of pregnancy). However even if a woman comes late in her pregnancy for registration, she should be registered and care given to her according to gestational age. Minimum three antenatal check-ups: First visit to the antenatal clinic as soon as pregnancy is suspected/between the 4th and 6th month (before 26 weeks), 2nd visit at 8th month (around 32 weeks) and 3rd visit at 9th month (around 36 weeks) Associated services like general examination such as height, weight, blood pressure, anaemia, abdominal examination, breast examination, Folic Acid Supplementation in first trimester, Iron & Folic Acid Supplementation from 12 weeks, injection of tetanus toxoid, treatment of anaemia etc., (as per the Guidelines for Antenatal care and Skilled Attendance at Birth by ANMs and LHVs) Minimum laboratory investigations like haemoglobin estimation, urine for albumin and sugar, and referral to PHC for blood grouping. Identification of high-risk pregnancies and appropriate and prompt referral. Counselling on diet & rest, pre birth preparedness and complication readiness, delivery kit for home deliveries, danger signs, infant & young child feeding, initiation of breast feeding, exclusive breast feeding for 6 months, demand feeding, supplementary feeding (weaning and starting semi solid and solid food) at 6 months, contraception, advice on institutional deliveries, clean and safe delivery at home, postnatal care & hygiene, nutrition, care of new born and registration of birth.