The New Nation - Internet Edition

Ensuring a better mother-health service

Neeta Lal

Last year, Kamla, 28, a poor farmer in Rajasthan's Dholpur district, was flabbergasted to see her eight-month-old foetus pop out of her uterus as she toiled in a field.

Bleeding profusely, the hapless woman fainted on the spot. Thankfully, Kamla's co-worker, Sunehri, kept her wits about her and rushed to a phone booth to contact a local obstetric helpline. Within minutes, a van taxied in to ferry Kamla to a local hospital where she safely delivered a baby boy.

For scores of mothers-to-be like Kamla, the Janani Suraksha Obstetric Helplines - set up across 28 districts in Rajasthan under the Central government's Janani Suraksha Yojana (JSY) scheme launched in 2005 - are proving to be a blessing. A pan-India, safe motherhood intervention project under the National Rural Health Mission (NRHM), JSY aims to whittle down maternal and neo-natal mortality by promoting institutional delivery among poor women. Overall, the project hopes to ensure that the Maternal Mortality Rate (MMR - number of deaths per 100,000 live births in a year) declines from 400-plus to 100 and the Infant Mortality Rate (the number of deaths per 1,000 live births) from 55 to 40.

Rajasthan's 28, 24-hour helplines, which were set up in 2006 are also supported by UNICEF. Apart from assisting pregnant women with early registration at a local health centre, the helpline workers also take charge of antenatal and postnatal care and arrange for transport to the health centre at the time of delivery.

In case a woman reaches on her own to the first referral unit, re-imbursement of transportation expenditure is made under JSY. And if she is not registered under the scheme as a beneficiary, payment is made for transport by the helpline staff.

UNICEF inputs under the scheme include technical support, funding to train resource persons and grassroots functionaries, conducting sensitisation workshops to familiarise communities with the helpline system (especially its emergency phone number), workshops with private vehicle operators and the infrastructure cost.

The JSY helpline system works seamlessly. Once the emergency call is received, the staff immediately contacts a registered taxi, which picks up and ferries the pregnant woman to the nearest health centre. At the centre, the helpline staff coordiantes the patient's admission and hospital stay.

The initiative works on a simple system of mobile connectivity. Currently, 28 NGOs in Rajasthan have been tapped to operate in select blocks in as many districts. About half-a-dozen field workers in every block have been given a mobile phone each. The

helpline numbers have been provided by Bharat Sanchar Nigam Limited along with 178 mobile handsets for workers under the project.

One of the most important positive outcomes of this programme has been that all across Rajasthan - the first state in the country to boast of such helplines - the well-being of the mother/newborn is increasingly becoming a close-knit community affair. As the JSY helpline focuses on a strong referral service for women with obstetric emergencies, all vehicles (state or private?) in the covered villages/blocks are identified and registered. In cases of emergencies - when pregnant women need to be rushed to health centres - the referral service is made available immediately. A strong network is also built among the vehicle owners, people with access to telephones and cell phones. This ensures that the doctors/medical staff is present at the local medical centre when the pregnant woman arrives. Much emphasis is laid on the involvement/support of the local people to make the project a success. Says an NRHM official, "From being just a pregnant woman's responsibility, childbirth has now assumed the importance of a community exercise, where everybody pitches in to ensure the well-being of the mother and the newborn. This is a very healthy sociological development."

Indeed JSY's helpline hasn't come a day too soon considering India accounts for a sizeable 20 per cent of the world's maternal mortality cases, according to UNICEF. Worse, in Rajasthan, low literacy, poor infrastructure and poverty ratchet up this ratio to an alarming 445 per 100,000 births - one of the highest in the world. According to the UN, more women in India die during pregnancy and childbirth than in any other country in the world. India's MMR is thus disquieting with one pregnant woman dying every five minutes.

According Paul Hunt, a human rights expert with the UN, who was in India recently, India's MMR is "shocking" for a middle-income country. Hunt stated that the Indian MMR is six times that of China's, 14 times that of Chile's and eight times worse than even Cuba's, a country, which has been witnessing political upheaval for the past few years.

"Most of the maternal deaths in India are avoidable as they are caused by poor nutrition, abysmal antenatal care, home births which trigger delivery complications and poor access to health clinics," says a health project officer for UNICEF in Rajasthan. Poverty, poor transport and health infrastructure force over 70 per cent of the women in the state to deliver at home which could result in maternal deaths due to haemorrhage, eclampsia, infections, obstructed labor, abortion and anemia.

"Due to insufficient health information, the poor often think that if a pregnant woman has pain or bleeding, it is part and parcel of a normal delivery," says the health officer. "This misinformation often reduces mothers-to-be to a 'maternal death' statistic."

The World Health Organization (WHO) defines "maternal death" as "death of women while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by pregnancy or its management."

While there are various reasons for India's high MMR, including early marriage and childbirth, lack of adequate health care facilities, inadequate nutrition and absence of skilled personnel worsen the situation. The level of maternal mortality is an indicator of the socio-economic growth and the health conditions of a society.

Though official figures of the JSY's helpline scheme's efficacy are yet to be tabulated, there's no denying that the intervention programme has altered the community dynamics in Rajasthan by focusing more on the health of pregnant women and newborn children. Consequently, it has also improved pregnancy outcomes through institutionalised deliveries.

Medicine at our doorsteps: Durba

Jamayet Ali

Durba is a perennial creeping grass and flowering all the year round; grows everywhere throughout Bangladesh. It is particularly abundant on road-sides and paths, and readily takes possession of any uncultivated area. It grows on all kinds of soil, even on alkali soil, but prefers heavier types. It flowers nearly throughout the year. The grass is one of the best for lawns and turfs. It is considered to be a good soil binder and is one of the plants recommended for checking soil erosion. Once established the grass is difficult to eradicate. It is a serious pest of cultivable lands, and its thick net-work of runners practically starves out crops, and vast areas of good fertile land are rendered unfit for cultivation. Deep ploughing and hand digging during hot weather and exposure to sun, have been found useful in checking its spread. In winter it appears scanty, at which time it may be said to be at rest.

Botanical name of Durba is Cynodon dactylon Pers. It is a valuable pasture grass, almost the only one that keeps green during hot weather, and provides more and better grazing for cattle and horses than any other grass. It can be cut and fed green, or made into hay. It is the most common and useful grass in India also.

A cooling drink is said to be made from the roots. Its stems as well as its roots form a large proportion of the food of our horses and cows. Even this grass is very eagerly eaten to the cows for having large quantity of milk.

It is considered to be a first class fodder grass in Australia, where it is widely distributed though in all probability introduced with cultivation. This grass is highly valued in the United States, where it is generally known under the name of Bermuda grass. Medicinal Properties: The plant is acrid, sweet, cooling; useful in biliousness, thirst, vomiting, burning sensation, bad taste in the mouth, hallucinations, epileptic fits fatigue, leprosy, scabies, skin diseases, dysentery, fever, erysipelas, epistaxis (Ayurveda). The plant is bitterish; vulnerary, expectorant; useful in vomiting, diarrhoea, cobra-bite, burning sensation, diseases of the blood, stomatitis, epistaxis, bruises, biliousness, hiccough (Yunani).

The express juice is astringent and is used as an application to fresh cuts and wounds. It is also diuretic and is used in cases of dropsy and anasarca, also as an astringent in cases of chronic diarhhoea and dysentery. It is also useful in catarrhal ophthalmia. The expressed juice is used in hysteria, epilepsy, insanity. In the Konkan, the grass is prescribed in compound decoctions with more active drugs for the cure of dysentery, menorrhagia.

A white variety, which appears to be only a diseased state of the plant, is used to check vomiting in bilious complaints. A preparation of the plant is applied by the Santals in parasitic disease, which attacks the spaces between the toes. The roots crushed and mixed with curds are used in cases of chronic gleet.

A cold infusion often stops bleeding from piles. The decoction of the roots is used in Mysore for secondary syphilis. The Mundas use it as a diuretic, especially in dropsy. In Madagascar, the whole plant, or the rhizome alone, is applied topically in gout and rheumatic affections. Europeans in the Transvaal use the plant for hurtburn. It is taken bruised and mixed with sodium bicarbonate and other substances. The bruised plant alone is applied as a styptic to wounds. The xosas use the decoction as a lotion for sores and swellings. The plant is not an antidote to either snake-venom or scorpion venom. (Indian Medicinal Plants, K.R. Kirtikar & B.D. Basu, Vol. N, 2690) Properties and Uses: The grass is used to treat inflamed tumours, piles, Twhitlows, toothache, echzema, excessive menstrual discharges and leucorrhoea, and to stop bleeding from cuts and wounds. Fresh juice is demulcent and astringent, stops nosebleeding and cures skin diseases and is used in cases of dropsy, anasarca, hysteria, epilepsy, insanity, chronic diarrhoea and dysentery.

It also acts as a diuretic and is used to stop vomiting and to treat catarrhal ophthalmia. Decoction of the roots is valuable in cases of vesical calculas, secondary syphilis, dysuria and irritation of the urinary organs. Extract of the plant possesses antiviral, antifungal, hypoglycemic, diuretic and antilithic properties. (Medicinal Plants of Bangladesh, Abdul Ghani, Second Edition ).

Medicine: In the Athawana Veda it is said: "May Durba, which rose from the water of life, which has a hundred roots and a hundred stems, efface a hundred of my sins, and prolong my existence on earth for a hundred years." U.C. Dutt says: "This elegant and most useful vegetable has a niche in the temple of the Hindu religion. medicinally, the fresh juice of the leaves is considered astringent, and is used as a snuff in epistaxis. The bruised grass is a popular application to bleeding wounds."

It seems probable that both for sacred as well as medicinal purposes this grass is often confused with Eragrostis cynosuroides. The latter is the Kash, Darbh or Dab (the Gramina of the Portuguese and the Gramen of the Romans but not the Triticum repens of the Greeks); it is used extensively at funeral ceremonies of the Hindus, the chief mourner wearing a ring of the grass. The latter is sacred to Ganesh. Both grasses are indiscriminately used in compound prescriptions with more powerful drugs in the cure of dysentery, menorrhoegia. Sakharam Arjun says: "A white variety, which appears to be only a diseased state of the plant, is used medicinally by the native practitioners. It is acidulous and is used to check vomiting in bilious complaints." Rev.

A. Campbell says of the Santals: A preparation of the plant is applied in a parasitic disease, which attacks the spaces between the toes. This disease may be the same as that which is common in the West Indies, caused by Pulex penetrans."

Special Opinions: "The expressed juice is astringent and is used as an application to fresh cuts and wounds. It is also diuretic and is used in cases of dropsy and anasarca, also as an astringent in cases of chronic diarrhoea and dysentery" (Civil Surgeon J.H. Thornton, B.A. M.B., Monghyr) "The juice of the green grass is used in catarrhal ophthalmia, is astringent, used also with much benefit in hoematuresis" (Surgeon-Major J.M. Houston, Durbar Physn., Travancore, and John Gomes, Medical Store-keeper, Trevandrum). "I have found the fresh juice to be a very valuable styptic in epitaxis" (Doyal Chunder Shome). "Antiperiodic, used as an application in scabies" (Civil Surgeon Jhon McConaghey, M.D. Shajahanpore). "The decoction of the roots is used in Mysore for secondary syphilis" (Surgeon-Major John North, I.M.S., Bangalore) "The decoction of the root chiefly used as diuretic" (Y. Ummegudien, Madras) , A cold infusion of durba grass often stops bleeding from piles. I generally give it with milk" (Civil-Surgeon R. L. Dutt. M.D. Pubna).

"Used in irritation of the urinary organs" (Assistant Surgeon T. Ruthnam Moodelliar, Chingleput, Madras Presidency) "Expressed juice is used by the Hakims as an injection in the nostrils for epitaxis. The bruised grass has been used by the Hindus from very ancient times as a dressing for fresh wounds, probably on account of its styptic properties" (Assistant Surgeon Nobin Chunder Dutt. Durbhanga). "The roots crushed and mixed with curds are used in cases of chronic gleet, dose 3ii" (Surgeon James McCloghay, Offg. Staff Surgeon, Poona) (Dictionary of the Economic Products of India, Watt, Vol. II, 679, 680)

Patient ratio and the upcoming 'national health policy'

ABM Moniruddin

The Ministry Of Health & Family Welfare of Bangladesh claims that the country has a doctor patient ratio of 1:3169 (as declared by the health adviser on 06-04-2007 in the conference hall of that ministry), considering all the doctors (42,881) registered so far with the BM & DC. However, there is a gross error in the report of working Physicians (Govt. & Private) available for care & treatment of ailing patients. Because, many of the doctors (42,881) registered so far with the BM & DC have already expired (dead) & many of the doctors (42,881) registered so far with the BM & DC have left Bangladesh, working abroad (most of whom will not return as they have undertaken the citizenship of foreign countries), & many of the doctors (42,881) registered so far with the BM & DC are no longer involved in care & treatment, that is, they are either involved in business or some other profession, or retired, i.e., they are quite old & disable for involvement in care & treatment of people of Bangladesh. When all these factors are rightly considered, number of working, living Physicians (Govt. & Private) available for care & treatment of ailing patients would be probably less than 13,000. Thus there seems to be a gross error in the report of working Physicians available for care & treatment of people of Bangladesh.

This error needs to be corrected. It is very sad to state that as the Ministry Of Health & Family Welfare is run by bureaucrats who de facto possess no responsibility sincerely will take no step to correct the statistical errors of health. Still it is the prime responsibility of the Ministry Of Health & Family Welfare to correct all discrepancies in health statistics.

The Ministry Of Health & Family Welfare in collaboration of Directorate General of Health Services & BM and DC should first enlist the registered doctors who are living & working in Bangladesh. The BM & DC should enlist the registered doctors who have already expired. The BM & DC along with the Ministry Of Health & Family Welfare should also enlist the registered doctors who are no longer involved in care & treatment of ailing patients, that is, they are either involved in business or some other profession, or retired, i.e., quite old & disable for involvement in caring & treating people of Bangladesh. Moreover, a good number of registered doctors are involved in health administration, who are in no way directly involved in caring & treating patients. They should also be enlisted. The Ministry Of Health & Family Welfare in collaboration of Directorate General of Health Services & BM and DC should also enlist the registered doctors who left the country for job & also for job plus citizenship abroad. The Ministry Of Health & Family Welfare can't avoid its pivotal role in correcting all existing discrepancies in health statistics.

It has been learnt that at present there are 6,220 posts of graduate MBBS doctors & 2229 posts of qualified diploma nurses are lying vacant in the governmental sector. Not only that, a huge number of manpower amounting to 30,367 posts / personnels are lying vacant throughout the country.

It is the prime responsibility of the Ministry Of Health & Family Welfare of Bangladesh to take initial necessary steps to appoint manpower against these vacant posts. But it is very sad to state that the Ministry is quite careless & indifferent to perform its sacred duty. Rather the said ministry is engaged to promulgate a 'National Health Policy' based on very very weak foundation to vicimize the innocent working doctors.

The ministry abhors the existing labour rules & laws. It makes the EOC doctors bound work 24 hours in a day & 168 hours in a week, without any rest & pause. There is none in the government to see & to remove all these inhuman discrepancies in the health sector.

It is needless to say that when a country is having gross false statistics, all the plans, policies & programs based on false statistics are worthless. The Ministry Of Health & Family Welfare of Bangladesh is going to announce a 'National Health Policy' based on these false statistics, but empowered by the law & force of prevailing state of Emergency declared by his highness the hon'ble president. It is to be recollected that our population is increasing by 2.5 millions each year & the number of graduate et qualified doctors are not increasing proportionately.

Can we expect this CTG to extend its honest hand to solve these problems in the health sector for the greater interest of our beloved country & countrymen?