Quality of Care in Public Facilities: Still a Big Question Mark!

It is a well-known fact that delivering in hospitals is much safer than delivering at home. Hospitals have experts who can help provide the best care possible for the mother and the baby. There are nurses who look after the mother, provide her with emotional support, and counsels her throughout the painful progression of childbirth. It is assuring to know that in case of any complications, you will have immediate access to specialist care.

To extend the benefits to the rural section of the society, Janani Suraksha Yojna was launched by the government of India in 2005 to promote institutional deliveries in public facilities by providing conditional cash transfers to women. With the launch of this flagship program, the institutional deliveries have increased many folds throughout the country.

NFHS shows the increase in institutional deliveries from 40% in 2006 to 78% in 2010-11 across India. With the advent of JSY, it is considered that increase in institutional deliveries will be accompanied by improved quality of care, but that is not the case. With the increase of caseload in the facilities, a lot is left to be said about the quality of services in public facilities. Many women coming to public facilities for maternity care face disagreeable circumstances on a daily basis.

Few such instances were highlighted while exploring the quality of services in few public healthcare facilities in Uttar Pradesh.

A 22-year-old Pushpa Devi came into the facility during the wee hours of one morning with labor pains. She was accompanied by her mother-in-law and husband. The attending nurse checked her once on admitting her in the facility and then completely disregarded her for the next couple of hours stating that there was sufficient time for delivery. Throughout her ordeal, Pushpa laid on her bed, crying with pain, while her mother-in-law tried to get the attention of the nurse to examine her daughter-in-law.

When the nurse came to check up on Pushpa, she criticized her for the lack of care of her genitals. The woman’s vaginal discharge had an awful smell which she couldn’t tolerate. She left her again, stating that she will return only when the head of the baby was visible. On constant pleading with the staff, the nurse came back, poured Sarson ka Tel (mustard oil) over her genitals, performed episiotomy (an incision made in the perineum during childbirth to facilitate easy delivery of the baby) which is a common malpractice in first childbirth and delivered the baby within 15 minutes. All this while, she scolded Pushpa and called her ‘dirty.’

This is just one incidence wherein the pregnant women was not given attention, she was ignored, disrespected and mistreated.

Corruption

It is a common practice to extract money from the family of the woman coming to the facility for delivery. This is worst in maternity wards. From the free ambulance service that transports the woman to the hospital, to the staff in the facility, demand money at every step to do their job. Relatives are asked to pay token amount before handing the newborn to the family, double the amount if the baby is a boy. A news report highlighting this form of endemic corruption describes the vicious cycle of the poverty trap that a poor family falls into while availing delivery care services from a public facility. A report on Maternal Mortality in India by the Centre for Reproductive Rights, describes that the case is worse for a poor woman who have to pay a huge amount for lower quality of care which serves as a deterrent against seeking institutional care and leads to higher pregnancy-related complications. A sub-standard quality of care compiled with under-the-table payment, creates a ‘poverty trap’ for the family, which turns this happy occasion into a sour experience.

Harmful practices

With an increase in the caseload of women coming to public hospitals for delivery, the overburdened staff employs unnecessary and many times harmful procedures to speed up the process of delivery. An article (Sharma JB, 2009) discusses such childbirth practices in public facilities, which are being employed unnecessarily such as induction of labor, applying pressure on abdomen, episiotomy, manual exploration of the uterus for removing placenta, etc., which are still being widely practiced in spite of evidence of their harmful effects. On the other hand, useful practices like the use of partograph for monitoring labor, delayed cord cutting, practicing active management of the third stage of labor, or sterile cord-cutting are not been regularly followed. Episiotomy is a routine procedure employed in primigravida women or those delivering for the first time. An article in The Journal of The American Medical Association found that routine episiotomy has no direct benefit. In fact, many studies have indicated that the use of episiotomy leads to many complications such as incontinence of urine, incontinence of stool, painful condition, etc. Despite this fact, the incidence of episiotomy was very high which was highlighted in a population-based study conducted in Chennai (Sathiyasekaran et al, 2007) where it was seen that in 67% of the cases, episiotomy was employed. In another study highlighting the benefit of JSY on institutional deliveries, it was found that in 79% of cases oxytocin was used, while in 57% of cases pressure was applied on the abdomen to hasten the process of labor.

Behavioral aspects

Cases like Pushpa are very commonly faced in public facilities, especially by poor sections of society. An article described many incidents where women in public facilities are slapped, shouted at, threatened, and neglected during their delivery. In a common scenario, public hospitals are so packed with patients that they have to settle in dirty corridors, whereas the hospital staff are plagued with long duty hours handling many patients at a time. But does this give them an excuse to disrespect, ignore and misbehave with patients?

Sensitizing health care professionals towards patient needs, especially during delicate experiences such as childbirth will help in improving the quality of care. At the same time, it is imperative to think ‘how far can one expect an overburdened physician to provide emotional comfort to his patients.’

With the advent of JSY, institutional deliveries have clearly increased in facilities in the past few years, but the question remains: Are the facilities able to cope up with the increase in caseloads? There still remains a dearth of healthcare professionals in proportion to increase in patient ratio. It is not fair to healthcare professionals, expecting them to handle 20-25 cases of deliveries in a day following all the prescribed protocols. There is a need of interventions such as the NIPI-UNDP initiative- Yashoda, a mother aid, who not only provides emotional support to women during their delivery but also counsel her on important aspects such as breastfeeding, immunization, skin-to-skin care, etc. We also need a strategy at the policy level which addresses the gap between available resources and increase the demand for delivery care services to ensure good quality of care.