Context – Monthly taluk meeting of all government medical officers (MOs) in the taluk. The MOs were asked for their suggestions to strengthen the health services in their taluk.
Among various issues raised, one issue was about the lack of obstetric services at the taluk. In the past 7 months, there have been only 305 deliveries at the PHC level and 85 deliveries at the Taluk Hospital. This, against an expected 2,500 deliveries. This means that the rest of the 2000 women have delivered either at the district hospital or at private nursing homes. The MOs provided some insight into this situation.
The ANMs at the SCs were very good in delivering women. Some of them would conduct 10 – 20 deliveries in a month. But suddenly, now the ANMs have been told not to deliver at the SC and that all the patients have to be sent to primary health centres (PHCs). So this has created a lot of problems for the patients. “We should have recognised their competencies and skills and allowed those who can conduct deliveries to continue, rather than centralising everything.” One of the MOs
At the PHC, there is only one MO and one ANM. Usually neither stay at the primary health centre as the facilities are very limited. There are no quarters usually. Where there is a quarter, there is no running water, no toilet facilities and no good schools nearby for the children. So the staff do not want to admit a patient for delivery, lest they have to stay back after 4 pm. So they refer these patients to the nearest facility – the 24 x 7 PHC.
The 24 x 7 PHC is expected to provide nursing services round the clock. It usually has one MO and 3 staff nurses (SN). These SNs are on continuous 8-hour duty, for 7 days a week. If any of them fall sick or have to take leave, then the other two have to manage by doing 12 hours duty. Naturally they find it difficult to handle any complicated deliveries, as it means a lot of tension for them. Rather they prefer to refer any ‘complicated cases’ to the taluk hospital (TH).
This is made worse by the patients, who want a definite answer to their question – “can you handle this delivery here? Will you guarantee us a healthy mother and child?” Since this guarantee is not possible, and since the threat of mob attack if there is any poor outcome is a reality, the nurses prefer to refer the patient.
And the last straw for the PHC staff is the maternal death audit. They are terrified about this and clearly state that the “doctors and the nurses do not want to take a risk. Better to refer the patient, than get caught up in the unnecessary problems of audit and the public humiliation that we experience.”
At the TH, there is only one obstetrician. He / She is expected to provide out-patient services from 9am to 1pm. And is then invariably asked to go for a laproscopic camp in some PHC area. After that he returns to do night duty. Which means that he is off on the next day. And for the next four nights, when other specialists are on night duty. While a surgeon can easily handle a medical or an orthopaedic patient, they have limited skills to manage an obstetric patient. This is because they have specialised in surgery, not obstetrics. It is like expecting a plumber to build a door. Or an engineer to argue a case in court. So any obstetric patient who lands at the taluk hospital on a day or period when the obstetrician is not on call is then referred to the next level, i.e. the district hospital. While TH specialists are able to handle non-obstetric cases, they are not willing to take the risk of managing a delivery. “We are in between the mob and the maternal audit. Why should we take any risk? All we have to do is refer the patient. Now with ‘108’ ambulance services, this is not a problem. So patient is happy and the doctor is happy.”
Maternity ward in India
What about the expenses for the patient and the government? A trip to the district hospital by 108 ambulance means that the government has to spend Rs 45 per km for this referral. Not to mention the burden on the district hospital. And of course the patient has to pay for a lot of indirect expenses, like transport, food, etc. There was no answer to this question. The implicit message was ‘– as long as it is out of my area (facility), then I am not bothered. I should not get into trouble.’
Various recommendations for solving this problem were provided, ranging from building the capacity of ANMs to manage deliveries, to increasing the staff at PHCs and 24×7 PHCs and THs. One suggestion that kept coming was – why not centralise all deliveries at the Taluk Hospital, employ 3 obstetricians and 3 anaesthetists and provide all obstetric services there. When challenged about the difficulty in getting obstetricians and anaesthetists, one suggestion that came up was whether the TH could make a panel of local private obstetricians and anaesthetists and call them when necessary. “One obstetrician full time may not be possible as it takes a long time to recruit and then if this one person leaves, we are back to the same situation.” However, a panel of specialists (similar to the practices of private nursing homes) may be feasible. If one doctor is not there, we can call the next on the list. This way, the government only has to reimburse the services of these private specialists, without taking the burden of recruiting them etc.
The other suggestion that came up was to use this money to incentivise the government obstetrician for every LSCS conducted at the TH. This will encourage optimum use of resources plus will be an incentive for the obstetrician. “Why should I work for 35,000 pm, while a junior and less experienced obstetrician recruited on a contractual basis gets 70,000 pm. If you give me that 70,000, I am willing to put in the extra effort to provide all the necessary services. And I do not have to go to the private nursing home, conduct deliveries to earn 3000 per delivery. I will have the peace of mind that I am not breaking any rules” – an obstetrician at the TH.
So it is not surprising that less than 20% of the pregnant women in this district are delivering at the most appropriate level and facility. The rest of them have to weather the problems of multiple referrals, uncertainty of services and finally meet the costs of all this.
