This blog is about what I observed and experienced as being one of the many, but the only male, attendants at a labor ward of the tertiary maternity hospital in Bangalore. This is in context of a minor (girl) with risk pregnancy who was admitted to and looked after by urban health project team after she was found to be in labor for 24 hours by our community health assistants at her in-law’s home. There was no support from family.
Roopa, my senior colleague, managed to assist in admission and investigations, following which the expecting mother was in what is called ‘clean’ labor ward (yes that’s how it is officially called). I took over duty as patient’s attendant from Roopa to be over night at hospital along with my other colleague, Amrutha (who joined me little later in night) so that I can do run around that may be needed in case of emergency.
For me, it was a first experience of being at labor ward. It was a very busy scene there due to sheer number of cases to be handled by a few (post graduate medical student, an intern, a couple of Aayas) staff available. We witnessed some 15 deliveries that night. No attendant was allowed to accompany women in labor ward so we all were crowding near its entrance in the lobby where we were frequently shouted at by Aaya requesting us to be away. So only thing we can do is to sit in the lobby, hear screams of women from labor ward and wait till name of the woman who delivered is announced. It must be scary for women inside as they were lined up inside the ward and I suspect they were able to see other woman delivering.
Among all these, suddenly just past the midnight, a spiritual leader from the near by Mosque started praying in a loud tone just at the entrance of labor room for a new born baby just delivered by a muslin woman. To my surprise, staff did not interfere and did not pay much attention. But it took many women waiting outside the ward with surprise. Later, from long conversation with this gentleman who taught me meanings of prayers that I used to hear a lot in KG halli, I understood that this was a normal happening and he used to visit the ward often. Things were just back to normal and a doctor (all of whom happened to be women) came walking from another end of the ward with a blood covered new born in her hands. This stunned every one of us waiting in that corridor, with our eyes fixed to the baby and I heard many asking each other, “is that a live or dead baby?”
Few hours passed by and I realized that this was not the place for a man to be. Every half an hour, a security guy or Aaya will walk the corridor and drive out attendants especially men (as only one female attendant is expected to be there). I had to repeatedly explain that I needed to be there, being the only attendant. To qualify as sole attendant, I sat apart from Amrutha as if we did not know each other. Also I came to know to my surprise that there is no toilet for men in this hospital. I got familial with all the corners of the hospital in search of this sought after place and was finally directed by security guy to go out in the dark.
By 12.45 am, o
ur young mother delivered a male baby through normal delivery. What a happy news! Then came a challenge of keeping the baby with me till morning. Attendant has to sign the form taking responsibility of the baby as baby kidnapping incidents have been reported in past. This is where completely unrelated women in the corridor showered empathy and help. They helped me wrap baby with available cloths and taught me to handle the baby well, while explaining what they were doing in Tamil/Kannada – though they knew I do not know these languages. Most women who passed by asked one question “yenu magu”, and I soon learned to answer “gandu magu (male child)”. Some one asked “nimda?” (yours?). In fact some imagined me as driver of Amrutha’s car!
Finally by around 4.30 am when mother was shifted out from the labor ward, some strange guy with camera appeared from the dark end of the corridor asking to unwrap the baby and adjusting mother in a specific pose! I later understood he takes photos so that by the time of discharge, a computerized birth certificate can be handed over with photo and other details.
It was a night that made me wiser. I leant about maternity services; how to handle a newborn; few things about Islam; challenges of huge work load that few health staff somehow manages; and humanity of a common man. By early morning, I located a Sulabh Shouchalaya (public toilet) in the campus of the nearby hospital only to find me in a queue waiting for a manager to complete ‘Aggarbattis and routine chores’ before he can open the facility for us.
Recently, the Indian government launched health insurance schemes for the poor both to protect them from highhealth spending and to improve access to high-quality health services. This article aims to review the potentials of healthinsurance interventions in order to improve access to quality care in India based on experiences of community health insurance schemes.
Data sources
PubMed, Ovid MEDLINE (R), All EBM Reviews, CSA Sociological Abstracts, CSA Social Service Abstracts,EconLit, Science Direct, the ISI Web of Knowledge, Social Science Research Network and databases of research centers were searched up to September 2010. An Internet search was executed.
Study selection.
One thousand hundred and thirty-three papers were assessed for inclusion and exclusion criteria. Twenty-five papers were selected providing information on eight schemes.
Data extraction.
A realist review was performed using Hirschman’s exit-voice theory: mechanisms to improve exit strategies (financial assets and infrastructure) and strengthen patient’s long voice route (quality management) and short voice route (patient pressure).
Results of data synthesis.
All schemes use a mix of measures to improve exit strategies and the long voice route. Most mechanisms are not effective in reality. Schemes that focus on the patients’ bargaining position at the patient-provider interface
seem to improve access to quality care.
Conclusion.
Top-down health insurance interventions with focus on exit strategies will not work out fully in the Indian context. Government must actively facilitate the potential of CHI schemes to emancipate the target group so that they may transform from mere passive beneficiaries into active participants in their health.
Keywords: health insurance, quality improvement, access to care, community health insurance, realist review, India
As a researcher, this was another day of visit to KG Halli in our long series of interactions with the community, but this particular visit was critical from research and humane point of view. I had gone to to meet three women who had lost their babies recently. I was a bit apprehensive to go and talk with them though they had expressed interest to meet me. This was perhaps e my previous experience of feelings of helplessness when a woman had broken down narrating her story in a similar situation and the research team could only console her at that time.
I followed Leela (the community health assistant) to Ms Shagufta’s house in KG Halli. We got a warm welcome and we all sat on a mat on the floor. After an initial chat, she gave me a plastic carry bag with many sheets of paper in it. The ultrasound report stated intrauterine death (IUD). On further questioning, Mrs Shagufta shared that she had been to the nearby Maternity Home and the doctor had advised her to go to “big hospital” but she along with her husband took the decision to wait for two days and then see…… She visited the same doctor after two days, but it was too late!!! One wonders, if the baby could have been saved if the reason for referring to the bigger hospital was explained to the mother? or the consequence of delaying visit to “big hospital” was communicated properly?? Do the doctors in public hospital
have so much time considering the work load?? Or should they be spending few minutes if the case is complicated? Not sure where and what went wrong but the end result was one life was lost which was preventable!
We walked through the Bharathmatha slum and reached Ms Vimla’s house. Her house was a contrast to the surrounding area that was neat and things in the house were well-arranged.. While talking I could feel her frustration when she said in-spite of doing everything what the doctors had suggested, I lost my baby! This happened in one of the private medical colleges/hospitals, where she went for regular antenatal care (ANC) visit—that too every 15days as advised by the doctors for monitoring her blood pressure. All she knew about the reason for baby’s death was that due to her high blood pressure the baby was choked to death. She attributes the sudden rise in her blood pressure at that time to witnessing the death of women in labor opposite to her ……this in a way raises questions about the atmosphere women deliver which is supposed to be the one of the best moments of their life!! Are the concerned staffs in the labor ward even aware of the impact of this situation on women in labor pain? ………….I had no exact answer when she asked why did my baby die after half an hour of birth?
With many un-answered questions for possible reasons for death of babies, we walked to Ms Salma’s house. Met this young charming girl sitting next to her first child….her sister in law joined us….whom we knew very well so the talk went smoothly……it was obvious that this young mother had terrible experience while in the labor ward…..in one of the secondary public hospitals in Bangalore. She said she was shouted at for going there while in labor and was told “if things go wrong we are not responsible”…It is difficult to understand whether secondary hospitals should concentrate more on referred cases/complicated cases or on ANC? Or is this a way shying away from responsibilities and accountability?? To add to this, money was demanded by the aaya….she was repeatedly slapped during the process of delivery….constantly and repeatedly told not to scream if she did so the baby would die…finally it reaches a stage where the aaya sits over her chest to “PUSH” the baby. The out-outcome of all this torture was a still birth!! She had lot of praise for the doctor’s attitude but she said it was nurse and aays who were rude …but are the doctor not supporting this kind of behavior by not addressing and turning a blind eye to it ? Or are they helpless to address this? Is this not part of basic quality of care? The young mother goes through this stressful experience and lives with guilt of killing her own baby by screaming and she shared her decision that -“ I will NEVER go to hospital for delivery”. This time I had an answer to her question – the baby did not die because you screamed while in labor pain! Though I did not have immediate answers in the first two episodes, I feel that sharing the ‘unresolved’ and ‘unaddressed’ issues and concerns of the community would go a long way to actually resolve them and prevent future deaths.
Please note: Names are changed to protect privacy.
IPH (Institute of Public Health) & ITM (Institute of Tropical Medicine) are partners in the Health Inc project. Werner Soors elaborates on the development of the SPEC-by-step tool for layered analysis of social exclusion in health. Tanya Seshadri shares a practical example where the tool is pre-tested on the preliminary data of an ongoing RSBY (Rashtriya Swasthaya Bima Yojna) WHO-Alliance study.
Date: 18th August 2011
The full presentation can be downloaded here (3Mb)
Part 1 The twinned concepts of social exclusion/inclusion
We introduce the concepts of social exclusion, specifically social exclusion in health, and the interaction of social exclusion and inclusion. For the latter, the Indian example of reservation serves as an example.
Part 2 Development of the SPEC-by-step tool
We develop the SPEC-by-step tool: a generic, structured checklist to provide guidance for analysis of social exclusion in social health protection programmes. We take you through each level and step of the tool.
Pre-testing the SPEC-by-step tool on an existing dataset
We exemplify the SPEC-by-step tool as an eye-opener by starting to apply it on the preliminary data of an ongoing RSBY WHO-Alliance study. (A cautionary note: preliminary unclean data is utilised for this example to understand application of this tool and is not related to the ongoing RSBY WHO-Alliance study)
Articles in BMC journals are listed in PubMed and archived at PubMed Central.
National policies recommending routine iron supplementation. Understanding factors associated with receipt of iron in the field could help optimise implementation of anaemia control policies. Thus, we undertook 1) a cross-sectional study to evaluate iron supplementation to children (and mothers) in rural Karnataka, India, and 2) an analysis of all-India rural data from the National Family Health Study 2005-6 (NFHS-3)
ISSN 1471-2458
Article type : Research article
Submission date : 31 January 2011
Acceptance date : 3 August 2011 Publication date : 3 August 2011
The Institute of public health hosted a group of 10 Maastricht University students on an Exposure visit to India program.
The students were participants of the Honours International program at Maastricht university.
The 3 week program from July 11 – July 28 2011 focused on exposing the students to the health system of the country.
The program was directed to equip students with better skills, knowledge and practices about inter country public health sceneries with special focus on the differences between multiple health care systems and also the regional and cultural perspectives.The prime component of the program were exposure to field visits. The students were also provided with theoretical framework/background to link the observations made in the field, much better.
The main topics covered under the program were health care system in India, social determinants of health, communicable and non communicable diseases, child and maternal health care in India, health service organisation, community health and health care financing in India.
