It is well known in the medical fraternity that maternal and child care indices are the most important healthcare indicators of a country. In the past few decades, we have been successful in reducing the maternal mortality ratio to a significant extent. However, there is a lot more left to do, especially in the peripheral areas where access to good quality health services still remains a luxury for many.
Before starting my residency in Delhi, I worked as a medical officer in Uttarakhand State Govt Health Services. Joined freshly after completing MBBS, I joined a primary health centre in one of the border districts of the state. After first few months, I was made the in-charge of the PHC. Unlike many of the PHCs in peripheral areas, this PHC worked very well in terms of the services provided. 5 subcentres were attached to our PHC, with very hardworking ANMs. Ante-natal check-ups were regularly being done by the ANMs as well as at the PHC. My initial target was to complete my mandatory bond period anyhow, not knowing that these three years at the PHC would completely change my future perspective.
I would like to highlight the challenges to maternal health in the hills by sharing two of my personal experiences.
It was heavily raining in the month of August with landslides occurring every few hours. At around 2 AM in the morning, 108-ambulance came and brought a 26 year old second gravida female in labour. My colleague medical officer told me that he will handle the case and I need not to come. After around 40 minutes, he informed me that a normal child has been delivered but the mother is having postpartum haemorrhage. I immediately rushed to the labour room where I saw that lady was bleeding continuously. We tried all the resuscitative measures, but could not stop the bleeding. Meanwhile, I called the ambulance staff to come swiftly and shift the patient to the higher centre. The ambulance driver told me that due to landslide, the road to District Hospital is blocked with no chances of opening till tomorrow morning. We contacted the PWD officer for clearing the road, he replied that he is sending the bulldozer but will take at least 2-3 hours to reach. In the meantime, the patient’s blood pressure started falling, she became drowsy, in spite of our best efforts, she succumbed.
Another incident is of a 35 year old 4th gravida female in the 5th trimester. She was diagnosed to have anaemia and was given iron folic acid tablets by the ANM. There was poor compliance to treatment. One day, she came to the OPD for routine check-up. I counselled her about the need of iron supplementation in pregnancy. She said that she has to take care of 3 kids at home, most of the money is used for the children’s expenses and she doesn’t get to eat well, moreover, her village is not connected by road, she has to walk 3 kilometres through the hilly area to reach the PHC for checkup. Being busy in multiple household responsibilities, she forgets to take iron supplements. After about a month, I got a call from the district CMO that unfortunately some lady has died in nearby village and I was asked to go and find out the details of it. I enquired about the same from the concerned ASHA and ANM and found out that it was the same lady whom I was treating. She developed sudden antepartum haemorrhage and because of lack of transportation had to go to local Dai, who due to deficiency in training and resources, couldn't stop her bleeding and finally due to massive haemorrhage, she died.
From the above 2 incidents, I would like to highlight a few issues specifically related to maternal health services in the peripheral hilly areas.
Firstly, the issue of difficult terrain, many villages are still not connected by motorable roads, owing to policies, local factors and engineering feasibility issues. Due to low income, people usually prefer to go to work and earn, rather than climb up a hill and go to healthcare centre. Even if they are willing to come, it is humongous task for them. Motor connectivity is a big challenge in the hilly areas. These areas are heavily reliant on the government machinery. Private sector does not take much interest due to lack of paying capacity of these citizens.108-ambulance service has helped a lot, however, it can reach only to the motorable areas. It is sad that even after 7 decades of independence, we are still not connected to the remote parts of our country and our citizens have to pay for that with the cost of their lives.
Harsh weather and difficult terrain are natural conditions which are not under man’s control, however, the onus is on the public health officers and Family Physicians to find a way forward. A multi-departmental approach is needed for handling such emergencies, including the support of Public Works Department. A quick response protocol must be followed. This will help in swift transport of the patient to the higher centre or atleast to a place where trained professionals are available. Apart from solving acute emergencies, better road connectivity will also improve the health-seeking behaviour of the hilly populations which will reduce the future maternal morbidity and mortality significantly.
Family planning programme has been quite effective in providing contraceptive methods to the people, but a lot needs to be done. As was the case above, the lady already had 3 children and was pregnant again, repeated pregnancies, with superadded poor nutrition creates a situation of high risk of maternal mortality. Identifying the gaps in counselling and explaining the public in accordance with their local beliefs needs to be done. Regular training sessions with the ANM/ASHA will also help tremendously.
Providing quality health care in the peripheral hilly areas remains a challenging task. Apart from all the country-wide issues, socio-geographical difficulties are the biggest hurdle for healthcare for people in these mountains. Being the Generalists, Family Physicians can play a huge role in these difficult-to-access areas to reduce the shortcomings of our healthcare.
Being solution-oriented will be the key towards moving forward!