From inadequate infrastructure in local hospitals to accredited social health activists workers not reaching women in the tribal belt, the health system in the area is full of gaps.
Nashik, Maharashtra: Twenty-year-old Manisha Jadhav from Peth, a tribal taluka in Nashik district, gave birth to a premature baby girl in the seventh month of her pregnancy. The baby, who weighs less than a kilo, is now kept in an incubator at the hospital. Manisha, who is extremely undernourished, lives with her husband and in laws in a two-room mud hut, and said she toiled on her family farm well into her pregnancy. She was totally unaware that she could access government-sponsored medical care and nourishing food during her pregnancy.
It is because of cases like Manisha’s that when 55 newborn infants died in the hospital in August, neither the doctors nor administration were surprised or shocked. Infrastructure at the hospital is insufficient to meet the needs of the high number of newborns admitted in a critical condition. Add to that is the lack of awareness in the area and poor nutrition among mothers. The results can be devastating.
Nashik Civil Hospital is the only one with level 2 facilities in the district. It has to cater to the needs of patients from 15 talukas – approximately 61 lakh people – half of which fall under the tribal belt. Although there are a few private hospitals offering the services needed to treat premature babies, their fees are too high for the tribal families.
As a result, most babies in critical condition from across the district, and from the nearby Palghar, Thane and Nadurbar areas, are sent to the Civil Hospital for treatment.
Dr Pankaj Gajare, chief pediatrician at the hospital’s special newborn care unit, said, “We are a government hospital and cannot deny entry to anybody. And these tribal people are too poor to afford anything but free treatment. Often patients are in such poor condition that they die within 15-20 minutes of admission before we start treatment. Newborns with weight less than 1-1.5 kg need treatment at a level 3 hospital, which is in Mumbai. We cannot send patients to Mumbai in such a bad condition.”
But the health infrastructure is poor and consequently the outcome is horrific. Says Dr Gajare, “Fifty-five kids died out of the total 364 admissions in August. That means the mortality rate is 15%. Generally, the national mortality rate at a level 2 hospital is 10%. In the last five months, since April 2017, we received 1,492 patients, 187 of whom died, making the death rate 12%. Since the special newborn care unit was inaugurated in May 2013, we have received 13,885 patients, 2,885 of whom died. This puts the death rate at below 10%. The death rate was higher in August, since more critical patients were admitted that month.”
The hospital has only 18 incubators, but at any given time, there are at least 40 newborns in critical condition, leaving doctors with no option but to put more that one baby in an incubator at a time. Currently, 42 newborns are being treated at the hospital.
According to the resident medical officer Dr Anand Pawar, the hospital “has been requesting [the government] to increase infrastructure including incubators for the last two years. But somehow the proposals get postponed. But now, after the incident, Dipaka Sawant, health minister of Maharashtra, has approved 16 more incubators, 4 C-Paps (mini ventilators) and 16 nurses. The proposal for a tertiary care hospital has been approved.”
Lack of medical awareness in tribal areas
Tribal people in Nashik district are mostly unaware of the common medical conditions in the area or how to treat them. Most often, government healthcare workers identify whether a tribal patient needs to access medical facilities and sends them to a local hospital. From there, local doctors often send them to Civil Hospital using a 108 ambulance. However, the families of many patients in the area often do not have money to buy food. The problem is exacerbated further if doctors say the tribal patient needs purchased medicines or to be sent to Mumbai for further treatment. In such a scenario, tribal families often say they would have no choice but to leave their ill children in hospital and go back home.
Gajare said, “A month ago, a tribal woman gave birth to twins weighing 1 kg and 1.1 kg. The babies were admitted in the special centre unit. The parents left the hospital and the babies without informing the administration. Since then we have been taking care of those twins. We go beyond our duties and help patients. We do our best with the available facilities.”
District collector Radhakrishnan B. said that although better facilities are available at a hospital in Dhule, most people do not travel there. But why not upgrade the facilities at Civil Hospital? “As far as the issue of setting up infrastructure is concerned, this is a policy matter and we cannot do anything about it. We have already given reports to the government about the requirement of advanced medical facilities here. One more level 3 facility hospital is coming up in Nashik,” he told The Wire.
Pagare pointed out that babies born prematurely may develop congenital problems, like difficulty breathing and underdeveloped organs. Women with anaemia often tend to deliver babies prematurely.
Dr Shilpa Jadhav, a gynaecologist at Nashik Civil Hospital, said, “Girls from tribal areas, who are mostly not educated or school dropouts, are married at a young age. Their weight does not go beyond 30-35 kg and their haemoglobin count is as low as 2-6 grams, against the standard 12 grams. They get pregnant. As they are not aware of good food or medicines to be taken during pregnancy, they end up not taking care of their own health and thus the baby. Besides, they continue to work as labour in the farms till the time of delivery, worsening their condition and that of their babies. They work on farms in the heat, cold and rain, and don’t even realise if they are unwell. Because of this, the babies they deliver are not healthy. Many a times they deliver babies prematurely.”
Ranjana Janardhan Ahire, a 20-year-old tribal woman from Manmad, is admitted at Civil Hospital. Her baby was born prematurely, weighing just 960 grams, and has been in an incubator for a week. She lives with her husband and in-laws in a two-room house and works on the farm. When asked whether accredited social health activists (ASHA) workers (government health volunteers) gave her medicines and food, she said, “I have never received free food or medical care. ASHA workers would say money would be transferred to my bank account till the seventh month of pregnancy, but I don’t even have a bank account. During the seventh month, I was taken for a medical check up twice by ASHA workers.”
The Tribal Development Department provides supplementary nutrition, immunisation, health check ups, referral services, nutrition and health education, and cereals and pulses produced locally to pregnant and lactating mothers under the Integrated Child Development Scheme. ASHA workers are supposed to reach out to these expecting mothers and bring them under the umbrella of the Integrated Child Development Services.
However, tribal women are rarely aware of their rights and the schemes meant for them. Often illiterate, they are also afraid to communicate openly about their problems.
Sugandha Bendkule, a 22-year-old woman who weighs barely 40 kg and is from Samarpada in Karanjala village, gave birth to twin girls about 15 days ago. They weigh one kg and 1.5 kg, and are in incubators at the Nashik Civil Hospital. When asked whether she received free food and had done medical tests regularly during her pregnancy, she said, “Till the seventh month of my pregnancy, ASHA workers did not even visit me. From then on, I received free food at the neighbourhood anganwadi. Later, a sonography test was done twice. But I haven’t received anything else.”
Expecting mothers are supposed to be given calcium and haemoglobin tablets, and have sonography tests done monthly. They also need to be given all their vaccines on time.
But ASHA workers place the blame elsewhere. Banita Chougule, an ASHA worker from Samarpada, told The Wire, “We keep track of the monthly menstrual cycles of tribal women. If they miss a cycle, we take them to take pregnancy tests and start providing the medication and free food. But tribal women hardly cooperate. They don’t take calcium and iron support tablets as they give them nausea for some time. We have to insist that they go to get the vaccines, sonography tests and other medical tests. But on the day of the tests, they make sure to go to the farm early. We cannot go to farms to find them.”
She added, “Sometime their husbands or in-laws don’t send them to take the food or get medical tests done for reasons like there being work at home. These women don’t have Aadhaar cards and other documents, and we try to help them out with that too. But despite our counselling, they go to the farm to work and earn money while they’re pregnant. It is a difficult task to make them think about their own and their babies’ health. But still, we accompany them till the hospital for their delivery.”
V.P. Vamorkar, the chief nurse at the newborn care unit, said, “Poverty is a major issue. Families who are admitted here often don’t have money to buy food from outside. Many a times we help them to buy food. It’s big social issue.”
Radhakrishnan B., the Nashik collector, said, “Malnutrition is a major issue in Nashik, as a major part of the population is tribal. They are illiterate and unaware about the schemes. Despite that, we have been able to reduce the maternal and child mortality rates over the last three years. Besides, there are issues like insensitive staff that don’t try to reach to tribal areas and vacancies at offices. We are trying to overcome the problem to decrease the death rate.”