Expecting Trouble

  • Aliya Bashir
  • Publish Date: Jul 4 2017 9:50PM
  • |
  • Updated Date: Jul 4 2017 9:53PM
Expecting Trouble

A nurse explaining the condition of a pregnant lady to her relatives outside the gynecology ward of district hospital Baramulla

 

Yasmeen Nisa, 28, was planting rice saplings in her field at Aragam village in North Kashmir's Bandipora district when she fainted and collapsed. When she opened her eyes, she found herself lying under a blanket, writhing in pain.

That night, Nisa vomited throughout. Next morning, her husband, Gulzar Ahmed Wani, 33, took her to a nearby health centre, where a paramedic confirmed her pregnancy. The news brought back unpleasant memories – she had undergone two miscarriages in seven years.

Both miscarriages happened because of implantation bleeding. Her in-laws saw her as the carrier of misfortune. But her husband stood by her during this desperate period to have a child. He accompanied her to numerous faith healers to seek blessing and keep away bad spirits.

The couple decided to live separately. They were given a share in the property but for the past four years, Gulzar's family does not even visit them, let alone provide any help. They have to look after everything on their own. Nisa’s family is poor and they haven’t been able to help in any way.

Nisa is fragile; she weighs barely 50 kgs. The skin under her eyes is thin and wrinkled. She struggles to find time from farming and household work to visit the Bandipora District Hospital, 7 km away, for antenatal check-ups. “On every visit to the hospital, I have to walk around two kilometers and change at least two public buses,” she says. “It is always an excruciating experience.”

Women from various remote areas in the district visit the hospital in North Kashmir’s Baramulla district for maternity healthcare and travel many kilometers to reach the hospital. The barrier of distance becomes cumbersome especially during winters and when there are curfews or shutdowns

 

Bandipora’s roads are largely dilapidated despite the fact that road construction is generously funded by federal and state agencies, including the National Bank for Agriculture and Rural Development (NABARD) and the Union Ministry of Rural Development. Frequent rain and snowfall only worsens the condition of roads, exacerbating the problems of patients on their way to the district hospital.

For Nisa, walking the tough terrain during rain or curfew takes a toll on her health.

A gynecologist, who works as a senior consultant at the hospital, narrated her own harrowing experience of travelling on the road every day. “The road to Bandipora hospital is a silent killer, especially for pregnant women,” the doctor says. “It is a serious concern as women in the first trimester carry the risk of miscarriage and during the later stage, it would be risking early labour.”

This is one of the main reasons, the doctor says, why many pregnant women from Bandipora prefer to visit Maternity and Child Care Hospital in Sopore or hospitals in Srinagar farther away. But for women with high-risk pregnancies like Nisa, travelling longer distances is a double-edged sword.

Nisa is into her sixth month of pregnancy with delivery expected in late October. Every time she travels on the bad stretches of the road from her village, she complains of severe back pain, high blood pressure and stress. So, she has avoided many check-ups at the hospital.

In many areas of the district such as Gulshan Chowk, the locals have now pooled money to repair the potholed roads.

The 30-bedded district hospital was upgraded from sub-district hospital in 2009-10. But the hospital doesn’t even have a blood bank. There are few specialists. In the gynecology department, two surgeons and one anesthetist are available.

According to the 2011 Census, Bandipora district has a population of four lakh, almost equally split between men and women. Data collected by the hospital’s OPD indicates that 20-25 pregnant women visit for gynae-related issues every day. On an average, 100-110 deliveries take place every month, 17-20 of which are caesarean deliveries. Every month, about 120 expectant mothers from the district are referred to maternity hospitals in Srinagar — Lal Ded Hospital and Jhelum Valley Medical College Hospital.

Nisa’s medical records show she is severely anemic with 7gm/dl hemoglobin, hypothyroid, high blood pressure and excessive swelling in hands and legs, making it crucial for her to be extra careful for safe pregnancy. She takes two iron folic acid tablets every day, one in the morning and one in the evening. She has been advised by doctors at the hospital to undergo caesarean section and, thus, keep Lal Ded hospital as an alternative option for delivery given the lack of blood storage at the hospital. “It means I have to rent a place in Srinagar a week before my expected delivery date,” says Nisa. “We don’t want to take any chances with our third child.”

Since  the  National  Health Mission (NHM) was rolled out in the district in 2005,  there  has  been a  marked change  in  maternal  health. Federally-sponsored schemes like Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK) under the health mission encourage institutional deliveries by offering cash assistance and antenatal, post-delivery care as incentives. The cash assistance provided to a Low Performing State like Jammu and Kashmir is Rs 1,400 to the mother and Rs 600 to ASHA worker in rural areas and Rs 1,000 to the mother and Rs 400 to ASHA worker in urban areas. ASHA is an accredited social heath activist who facilitates access of women to healthcare.

Nisa’s husband expressed his dismay at the healthcare facilities available at the Bandipora hospital. He says he has spent around Rs 10,000 on ultrasound scans, supplements, medicines and other medical examinations since his wife’s pregnancy began. At the hospital, he was told not to worry about the delivery. But he is so frustrated that he wants to take a loan to pay for their stay in Srinagar city.

“Had our district hospital been well-equipped, we would not have needed to take a loan and make arrangements for stay in Srinagar,” Wani says.

The couple says they have never seen any ASHA worker in their area who could have facilitated their visits to the hospital or guided them about free services available for the pregnant ladies under JSY and JSSK schemes.

ASHA workers during an adolescent health camp at a Primary Health Centre in the block Rohama of Baramulla district

 

In rural areas, expectant mothers often suffer from malnutrition, anemia, low weight and other complications. The absence of better healthcare facilities within reach only compounds their problems.

Noor Jahan, 33, from Ketsan, a village eight kilometers from Bandipora town, was screaming in the OPD of the district hospital due to severe pain in her abdomen. She is a mother of five children who were born normally at home with the help of a midwife. Now, she wants to deliver her last baby at the hospital so she can immediately undergo permanent birth control.

Female sterilization is the most preferred permanent birth control option in the region. The National Family Health Survey-4 for 2015-2016 puts the number at 30.4 per cent in urban areas and 21.9 in rural areas as against 0.5 percent male sterilization in urban and 0.3 per cent in rural areas.

The doctor on duty at Bandipora hospital was angry at Jahan’s ultrasound report which showed her 11 months pregnant – a gross medical mistake. Jahan had no idea when her last menstrual period was or her expected delivery date. All she had was the report and no one was accompanying her to the hospital. “I am illiterate, I don’t know what they write on tests,” Jahan says. She was asked to do an emergency ultrasound scan without delay. “I have no money to do the test. I talked to my ASHA worker on phone but she said I will get Rs 1,500 after delivering the baby.”

Jahan had been encouraged by an ASHA worker to visit the hospital and get free services. “Earlier neither my husband nor my in-laws were ready for the institutional delivery, but the ASHA worker in my area encouraged me to visit the hospital,” Jahan says. “But she couldn’t accompany me today as she had to visit another lady who had to deliver in the hospital.”

Jahan says women in her village still prefer to deliver at home as it is difficult to visit far off hospitals and spend “our own money” on transportation.

The district hospital is around eight kilometers from her home and it is not possible to pay for frequent visits there, she says. “There are so many women in our area who complain they have not received the money more than a year after their deliveries,” Jahan says.

The government schemes for pregnant women, indeed, face daunting challenges in their execution. “All the applicable schemes are determined by the resources – manpower, material, time and money. In peripheral systems, we have manpower deficiency due to which the schemes are getting affected and we fail to deliver,” says Dr Muhammad Salim Khan, head of Community Medicine at Government Medical College in Srinagar. “But over the period of two decades, the quality of services has definitely improved.”

There are issues of transportation and free services not being provided properly as patients have to come from distant places, Dr Khan says. “But people are not aware that there are free transportation services as well. They prefer to come on their own and they hire their own vehicles,” he says. “For awareness, the media has a role to play.”

According to the Directorate of Health Services, there are 46 ambulances in Bandipora district, two of which are damaged and five are operational at the district hospital. The hospital functions out of an old building as a new multi-specialty district hospital is being built at Nusoo, a kilometre away, since March 2010.

Residents in the area hope the new hospital will reduce the need for them to visit far off hospitals. But construction of the hospital has missed many deadlines. The delay, authorities say, has occurred because funds are not released on time. “We are very excited to see the construction of the new hospital. Though the work is going on at a very slow pace, we are still happy that it is happening,” says Naseer Ahmed Mir, 39, a pharmacist outside the hospital. “It will benefit the people here in multiple ways.”

The hospital is mainly dependent for infrastructure and manpower on the NHM because the creation of posts by the state government is limited and there is much delay in the release of funds due to which the hospital suffers from staff shortage, lack of equipment and emergency drugs. As a result, doctors here have to send their patients to hospitals in Sopore or Srinagar, especially in emergency gynecology and obstetrics-related issues.

A doctor at the hospital who spoke on the condition of anonymity for fear of reprisal from his superiors says the hospital practically still functions as a sub-district hospital. “People see doctors as super-human who can do miracles,” the doctor says. “But we are humans. We too commit mistakes. We can only do our job when we have decent facilities and support staff.”

Due to overcrowding and lack of proper facilities in hospitals, even the best doctors make mistakes, the doctor says. The patient inflow keeps increasing but the staff strength remains mostly the same. “We can’t work 24×7,” says the doctor. “When there are only 1-2 specialized doctors who have to manage a huge rush every day, things become vulnerable.”

The gynecology ward of the 300-bedded Baramulla district hospital, where usually two pregnant ladies share a same bed due to the overload of patients

 

Another paramedic at the hospital echoed what the doctor had to say. He says every time they make a referral, they take a decision to minimize the risks. “In case of emergency, we always try to negotiate the best possible options with the patients but most of them always doubt our intentions,” the paramedic says.

Nagina Shiekh, 30, from Adoora Sheeri shared her bed with Shareefa Jan, 31, from Watergam, in Baramulla District Hospital in North Kashmir. Both were waiting for C-section deliveries. Shiekh has been waiting for her delivery for four days but due to her low hemoglobin level - 7gm/dl - her surgery was getting delayed. The doctor had advised that she be given two pints of O Positive blood which her family arranged. The transfusion increased her hemoglobin to 8.4 gm/dl and she was then advised to get another pint. "It was not easy to visit the hospital. It is a long way from my home. But still it is closer than any hospital in Srinagar,” Shiekh says. “We have done most of the tests, purchased medicines and visited the hospital many times at our own expense.”

She says she has received folic acid tablets many times from the hospital. “I was afraid to tell the doctors on their face that we don’t trust government medicines, especially when a few years ago there was news of hospitals selling spurious drugs,” Shiekh says.

Blaming her luck and overcrowded hospitals with limited resources, Shiekh says, “Had I been able to afford an operation in a private nursing home, I would have never come here. But we are poor and have limited resources.”

Another woman lying on the bed next to Shiekh says the way they are treated at the hospital could not get any worse. “We live in far-off villages and the staff here see us like we are beggars who have come for free treatment,” the woman, who didn’t want to be identified, says.

“We purchased all medicines and necessary items for the surgery on our own,” says the woman's sister who is attending on her. “One spends thousands of rupees on transportation, tests and medicines after travelling long distances and still the patient has to suffer in multiple ways.”

Relatives accompanying the expectant women to the hospital say transportation facilities must be made available to them. As per WHO guidelines, every 1,000 people should have one doctor, says Dr Khan. “Our ratio is around 1,700. So, we have around 60 per cent deficiency of doctors as per our population requirement."

The Baramulla hospital carried out 11,756 deliveries in 2016-17. Of these, 7,530 were normal and 4,226 were caesarean. At least, 1,624 pregnant women were provided free transport to the hospital and 3,659 with dropped home.

The Directorate of Health Services figures for 2016-17 show that Baramulla district received Rs 335 lakh under JSSK scheme and Rs 253 lakh under JSY. Also, 77 ambulances are available in the district, four of which are damaged. “In government, we have limitations because there is a hierarchical mechanism. We have our roles and responsibilities which we cannot go beyond,” says Dr Khan. “We cannot take our own decisions. Whatever orders and guidelines are there, we have to follow them.”

The doctor says making things smooth on the ground requires political and bureaucratic commitment to the implementation of various schemes.

Dr Saleem-ur-Rehman, Director of Health Services, Kashmir, says, “Our services are available right from sub-centre level to district level. Our focus is that we should get every pregnant lady to the hospital, and once we get her there, we will automatically take care of mother as well as child and ensure their safety.”

The NFHS-4 puts the number of institutional deliveries at 97.3 per cent in urban and 82 per cent in rural areas and home deliveries at 0.8 per cent in urban areas and 2.7 in rural areas.

The director says they have piloted a project in Pulwama district, where they take feedback from pregnant women and their families about healthcare facilities provided by the government. “We are going to do it across Kashmir. Our ASHAs will regularly track this feedback system like they are doing in Pulwama,” Dr Rehman says.

The government, he says, has also set up a control room to track patient referrals on a day-to-day basis.

However, women in rural areas, pregnant or otherwise, are mostly unaware of all these measures – to the detriment of their health and welfare.