Birth on the Threshold. Cecilia Van Hollen
(MPHW) schemes, modeled after the Soviet system, gained widespread acceptance and were implemented in many Indian states. These schemes called for both a male and female MPHW to be attached to each PHC. The male MPHWs were responsible for several vertical public programs, such as the leprosy, tuberculosis, and malaria programs, in addition to family planning. The role of female MPHWs has, however, been more limited in scope. Female MPHWs’ primary task has been to educate women, collect census-type data, and provide services in the areas of family planning and maternal-child health care more generally. As I discuss in Chapter Five, the family-planning interests and services have largely overshadowed all other aspects of MCH care in India since its independence.
MCH CARE STRUCTURE IN TAMIL NADU IN 1995
Rural Tamil Nadu: The Official Structure for Public MCH Care for Childbirth
This combination of the three-tiered public hospital structure, MPHWs, and trained (and untrained) hereditary dais formed the basis of the official rural public health service structure for MCH care in Tamil Nadu during my research in 1995. It must be underscored that the official structure does not always represent the actual structure of MCH care services in any given area at any given time. What follows in this section is an account of the official structure provided by the Tamil Nadu Department of Public Health.
In 1995 the population of Tamil Nadu was approximately 58 million.5 There were twenty-three districts. The city of Madras made up one district and the remaining districts comprised both urban and rural components. Each district had approximately fifteen to twenty “development blocks,” each serving a population of approximately one million.6 Within each development block, there was one PHC for every 30,000 people. In 1995 there were 1,416 PHCs in Tamil Nadu. Each PHC was to have at least five beds. The majority of the PHC services were outpatient, so few beds were deemed necessary. These PHCs were supposed to be staffed with two doctors (one female and one male), some paramedics, a pharmacist, and health support staff. Each PHC was to have one “sector health nurse” (previously called a “lady health visitor”) supervising six “village health nurses,” or VHNs (previously called “auxiliary nurse midwives” [ANMs]), the rural equivalent of urban female MPHWs. VHNs were responsible for MCH care, while male multipurpose health workers attached to the PHC were responsible for overseeing such things as public health, control of epidemics and specific diseases, and public emergencies. Each PHC was to have approximately six “health subcenters” (HSC) under its domain, which were overseen by the VHNs. In 1995 there were 8,681 HSCs in Tamil Nadu. In the plains areas where transportation was relatively easy, there was to be one HSC for every 5,000 of population. In areas with hilly terrain where transportation was more difficult, there was to be one HSC for every 2,000 to 3,000 of population. The VHNs attached to these HSCs were trained to provide essential obstetric care, including prenatal care, assistance with deliveries, postnatal care, family planning, and basic first aid for mothers and children. They were trained to detect emergency obstetric cases and refer those to the subdistrict-level hospitals, known as “taluk hospitals.” These VHNs were trained to conduct deliveries in a subcenter building, if such a building existed, or in patients’ homes. Only about 50 percent of all the HSCs actually had a building; the other 50 percent simply referred people to those services provided by the VHNs in homes.
In addition to the VHNs, the Department of Public Health also acknowledged that many home deliveries were conducted by local midwives, officially called “traditional birth attendants.” According to the Department of Public Health, there were approximately 40,000 TBAs in Tamil Nadu in 1995, and 90 percent had received some form of training from doctors in tertiary-care hospitals. The Department of Public Health strove to create linkages between the VHNs and the TBAs such that the TBAs would contact the VHNs if they detected any obstetric problems. The Department of Public Health also recognized, but did not deal administratively with, a category of people that it referred to as “nontraditional birth attendants,” which included members of the family who oversaw deliveries but who were not hereditary midwives.
For secondary health care, women and children were to be referred first to the taluk hospitals, of which there were approximately 200 in Tamil Nadu in 1995. After the taluk hospitals, patients would be referred to the “district quarter hospitals.” There were twenty-three district quarter hospitals in Tamil Nadu in 1995, one for each district in the state. Finally, for tertiary care, women and children could be referred to the large “government hospitals” attached to research institutions in major urban centers.
Kaanathur-Reddikuppam: Options for MCH Care for Childbirth in a Semirural Village
As I discuss in the Introduction, Kaanathur-Reddikuppam was undergoing rapid transformation as it was becoming increasingly connected to the metropolis of Madras. This had greatly influenced the structure of MCH services in the area such that in 1995 approximately one-half of all deliveries were conducted in homes and the other half in hospitals. There was, however, much variation in the nature of both home and hospital deliveries. This section will briefly describe the range of MCH services in this particular area, with the intention of providing a framework for understanding how people made decisions regarding which kind of services to seek for health needs related to childbirth.
My first introduction to Kaanathur-Reddikuppam was through Muttamma, who was working as a “lay first-aider” for the Voluntary Health Services (VHS) in Kaanathur and who also did some work for the Lion’s Club clinic in Muttukaadu. Muttamma was attached to the VHS “mini-health-center” (MHC), which was located on the main road in the middle of the small cluster of shops which made up the center of Kaanathur. The presence of this VHS mini-health-center, which was established in 1983, meant that the MCH services in this area already diverged from the official structure delineated above. Furthermore, although there was a government health subcenter building in the nearby town of Muttukaadu, south of Kaanathur-Reddikuppam, the post of VHN for the center was vacant during the time of my research. The building had not been used for deliveries for some time because it was damaged, and according to the block supervisor at the Kelambakkam PHC, the government had not provided the necessary funding to repair it. The VHN who was to fill that post was undergoing training in Madras during 1995. By the time I returned to Tamil Nadu in May of 1997 the VHN was working in the subcenter, though some complained that since she lived in the center of Madras her visits to the subcenter were somewhat sporadic and she was not available for off-hours emergency needs.
VHS was founded in 1966 by Dr. K. S. Sanjivi, a physician who strove to improve the health conditions of the rural poor.7 Sanjivi felt that completely free health care created passivity among people and made them feel that they were not getting quality care. Therefore, in establishing VHS he proposed providing health services along similar lines as those provided by the government but required that families pay a minimal fee for these services. During the time that I was conducting research the annual fee was Rs. 50 per family for use of the rural facilities. A one-visit consultation fee to see a private doctor would cost at least this much.
Sanjivi’s goal was to supplement rather than compete with preexisting government services. VHS’s funding came from a combination of government, business, and individual sources. Just as the government health services were provided through a structure of HSCs and PHCs, VHS care was to be provided primarily through a network of mini-health-centers. And like the HSCs and PHCs, these mini-health-centers were to focus on preventative care. VHS had established mini-health-centers in two development blocks near Madras, including the Thirupoorur development block within which Kaanathur-Reddikuppam was located. The Thirupoorur block was one of twenty-seven development blocks within the Chennai-MGR District in 1995.
The headquarters of VHS lay on the southern edge of Madras. At the headquarter hospital, doctors provided curative services for emergency cases. In addition, this hospital was engaged in research and trained medical officers (doctors), multipurpose health workers (male and female), and lay first-aiders. The lay first-aiders, like Muttamma, were all women and were chosen from among the women living in the communities where the mini-health-centers were located. The lay first-aider was a part-time worker who was expected to conduct home visits in order to collect information about the health status—including information about pregnant and postpartum women, deliveries, and family-planning methods