Maternity care in J&K: The Challenges and the Way Forward

Arka Chakraborty and Taitreyi Biswas

A robust healthcare system with universal health coverage, including primary, secondary and tertiary care is critical to the well-being of individuals. This fact, alone, should be enough to push the healthcare system up in the government’s list of developmental priorities. Having said that, the functionalities of the healthcare system still remains a matter of concern, especially maternal health care services during pregnancy. Maternity care is an extremely sensitive area of medical practice as the lives of both the mother and the infant(s) are at high risk, before, during and sometimes after childbirth. However, the majority of inhabitants in J&K face a plethora of challenges in seeking proper medical care for pregnant women.

Problems impacting maternity care in Jammu and Kashmir

1. Lack of proper facilities in rural and regional hospitals:

Most of the UT’s district and sub-district level hospitals lack the required infrastructure to treat mothers and infants, in case of any complications. The situation is so dire that according to a report published in 2018, the majority of the district-level hospitals don’t even have HDUs (High Dependency Unit where patients are moved in for increased care than a general unit but not to the point of ‘intensive care’) and ICUs (Intensive Care Units). Some of the other district-level hospitals lack facilities as basic as a blood bank. This contributes to the incompetence of such hospitals in treating even minor gynecological and obstetric complications, as a result the patients are often referred to the tertiary-level maternity care hospital — the Government Lalla Ded hospital — on a regular basis.

2. Transportation-related problems:

It is common knowledge that over-exertion is strictly advised against during pregnancy. However, the pregnant women in Jammu and Kashmir usually have to cover long distances and embark on arduous journeys to reach the maternity hospitals. This puts immense pressure on their minds and bodies. Generally, the lack of any trusted government transport system means that pregnant women often have to use public transport to reach hospitals. Things get complicated even more for them due to the dilapidated condition of the roads. In fact, a gynecologist has called the dilapidated condition of the road around Bandipora district hospital a ‘silent killer’ as the “over-exertion or injury caused by journeying on this road can lead to miscarriages especially during the first trimester”. It becomes quite clear why many women skip out on visiting the hospitals for regular check-ups during pregnancy. This already complicated issue is further compounded when patients from far-off districts and rural areas are referred to tertiary care hospitals in Srinagar and have to travel as long a distance (sometimes) as 75 kilometers. Expectant mothers often have to rent an apartment and spend a large amount of money just to ensure a safe delivery, expenses that could have been avoided only if district-level hospitals could serve them better.

3. Overcrowded tertiary-level hospitals and maternity care centers:

Due to the lack of infrastructure and manpower, the district and sub-district level hospitals refer the slightest complicated cases to the tertiary level institutions, most often the Lal Ded Hospital in Srinagar, these institutions have to bear the brunt of patient rush even with the existence of many district level institutions. Officials of the said hospital once confirmed that the hospital receives a huge number of referrals and as a result 130-150 new patients are admitted to the hospital on a daily basis, the number sometimes rising to 190 patients. The hospital’s Medical Superintendent Dr. Shabir Siddiqi confirmed that the hospital manages a huge rush, the OPD receiving 800-1000 patients daily. This huge rush affects both the patients and the medical practitioners negatively as on one hand the patients have to wait in long queues to have even a regular check-up and the medical practitioners, under such huge pressure, are bound to make some mistakes, which might end up costing lives.

4. Staff Crunch:

The lack of trained gynecologists, specialists and anesthetists is the main reason behind the unnecessary referrals to tertiary-level healthcare institutions. The shortage of medical staff is apparently a massive problem that J&K is currently facing. According to the report of a Manpower Audit (March, 2018) conducted by the Jammu and Kashmir health department, against the doctor-patient ratio of 1:1000 recommended by the World Health Organization and the doctor-patient ratio of 1:2000 in India on average, in Jammu and Kashmir, against every allopathic doctors, there are 3866 patients. This naturally puts immense pressure on the UT’s doctors and ultimately puts the patients at risk. According to a report of the Comptroller and Auditor General of India (CAG) (2017) on the UT’s health sector, the lack of trained staff in the UT’s medical field is staggering. According to this report, in 84 community health centers (CHCs) and sub-district hospitals (SDHs), there are only 270 specialist medical officers available against 504 available posts, signifying a 46% deficiency. In the district level blood banks, the condition is “even worse” with only 10 staffers available against the sanctioned strength of 132 posts. One is surprised to find that this staff crisis continues up to the tertiary level health institutions, with Lalla Ded having only 51 post-graduates (PGs), 28 registrars, 5 professors, 6 associate professors, 2 assistant professors, 2 senior consultants, 2 lectures and only one B-grade specialist. There is currently very little effort to fill up the vacant posts. Instead, when a new hospital comes up, staff are provided through ‘internal adjustments’ which only leads to cannibalization/deletion of old hospitals and ends up hurting both old and new healthcare institutions.

5. Lack of Hygiene:

One of the most common complaints against the hospitals (especially the public hospitals) of J&K is their unhygienic conditions which in some cases might lead to further infections and diseases. For example, patients complained that the Maternity and Children Hospital (MCH) at Sherbagh in southern Kashmir’s Anantang district suffer from irregularity and delay in the clearing up of garbage as well as stench and dust in washrooms.

6. Lack of Privacy:

Most of J&K’s district and sub-district level hospitals lack a separate space for expectant mothers. This results in both male and female staff members infringing upon the privacy of the mothers and putting their dignity at risk.

7. Inappropriate Behaviour:

Inappropriate exposure in J&K’s hospitals due to space crunch sometimes can lead to inappropriate behaviour towards the patients on the part of the staff, especially the paramedical staff. Shahnaz Khan, a resident of the Batamaloo area of Srinagar, alleged that when she was going through labour in a certain government hospital, she was slapped on the head by paramedical staff. A nurse even used bad language on her. During the extremely vulnerable and life-threatening stage of childbirth, a woman needs all the emotional support she can get, yet, according to Khan, women in government hospitals are subjected to ‘torture and abuse.’ In another case, a patient accused the staff at government hospitals of treating the patients like they were ‘beggars’ who had gone there for free treatment and treated them very poorly. Neelofar, a resident of the Rambagh area of Srinagar, accused a male technician of inappropriately touching her in the name of a Sonography. Allegations like these pop up often and many blame the staff members of government hospitals as being the chief culprits and, therefore, prefer to visit private hospitals.

8. The problem with private hospitals:

Various reports reveal that many people in J&K are tired of the abysmal service they receive at government hospitals and prefer private hospitals instead. However, private hospitals in J&K have problems of their own. Firstly, the March, 2018 report mentioned earlier shows that factors like difficult terrain and lack of incentives have led to very limited development of private hospitals in the erstwhile state, meaning that 97% of J&K’s population relied on public institutions for medical services. Secondly, the above-mentioned rarity and the fact that it is a private enterprise mean that private hospitals are too expensive for the general populace. In order to save their lives, some middle-class people spend a fortune to receive the kind of treatment that they deserve at public hospitals. The lower-middle-class and poor sections of the population, however, are too poor to afford even this. Thirdly and most importantly, the assumption that private hospitals are always a safer option than public hospitals because of their high expenses is illogical and unfounded. This becomes apparent with news of medical malpractices in private hospitals. For example, a private hospital at Anantang district used gas heaters in maternity wards which is extremely dangerous for both the mother and child.

9. Corruption:

There are unaddressed charges of funds misappropriation, the functioning of the hospitals and infrastructure development. There are even complaints of doctors in public institutions misinforming patients about medical complications and referring them to their private clinics or private hospitals owned by them or where they also work.

10. Issues of maternity health among the Tribal population:

The tribal population of J&K, according to the Census of 2011, consists of 11.9% of the region’s total population. Yet, this backward section of the region’s population does not receive any special assistance in maternity care. Most of the areas where the agriculturalist tribal groups live have no functional medical centers to cater to the needs of pregnant women. Living in the peripheral areas of the UT, expectant mothers belonging to tribal groups have to travel excruciatingly long distances to reach a hospital for delivery alone. This discourages them from any kind f regular check-up. The prevailing distrust in these groups for government-sponsored aides like the ASHA workers compounds the problem. To this is added a lack of awareness. There is very little knowledge of family planning among these groups as the use of contraceptives is almost unheard of.

Undue delay in infrastructure development, lack of awareness about centrally sponsored schemes for the benefit of medical care seekers and the utter lack of emergency medical services are some of the other problems that plague J&K’s maternity care sector.

Although the infant death rate in J&K is officially lower than the rest of India, major problems in the maternity care sector exist and it cannot be denied that these problems are causing avoidable health complications, suffering and even deaths on a daily basis. Despite public demonstrations and protests against the abysmal condition of J&K’s healthcare sector in general and in spite of the government’s repeated assurances, very little improvement has taken place so far.

Recommendations

1. The government should keep a separate section for accommodating pregnant women with necessary medical facilities and health care specialists such as gynecologists, obstetricians, physicians, anesthetists, and neonatologists. It should be strictly ensured that these measures are adopted both at the district and tehsil level.
2. Quality health services, especially in the sphere of maternity healthcare should be acknowledged in the healthcare system and at the societal levels. Initiatives should be taken to ensure that in providing healthcare discrimination should be prohibited at all levels, especially the forms defined by economic and social stratification.
3. Accessible and affordable healthcare is a delusion in most of the villages of Jammu and Kashmir. The degree of negligence showed by authorities regarding this problem is alarming. There should be at least one nursing home or any other healthcare structure within a kilometer of every household. If the geographical condition of the region does not allow the development of such facilities including an uninterrupted supply of power, machines, surgical instruments, then the authorities should build sustainable direct roads and transport systems connecting the villages to the nearest hospitals in minimum time.
4. A parallel route for health-related emergencies should be drawn on the same checkpoint so that precious time is not wasted by lingering in the common traffic created by these checkpoints that ‘generalize’ the necessity of each transport or vehicle.
5. With the provisions of the RTI, there should be a clear visual reflecting the bifurcation of the funds and money that the government spends in the development of healthcare in the state of Jammu and Kashmir, especially in the remote areas. With the same provision, there should be a proper and just calculation of the maternal mortality rates, so that at least the regional committees and NGOs, supplemental to the efforts of the state authority, could provide resources for health care development.

Conclusion

A news article published in June, 2019, aptly states, “Our healthcare institutions are diseased, how come they will treat the suffering people.” This disease has many faces and many forms. However, it can be agreed upon that one of the major problems that also act as a source of other problems is the paucity of trained professionals working in Jammu and Kashmir’s hospitals. This is the main reason behind the huge pressure on the tertiary level institutions (which are also under-staffed) and leads to mistakes and delays that silently kill mothers and infants. The first order of business, therefore, should be filling up the vacant posts of established hospitals with competent professionals instead of continuing to establish new institutions in vain. A strict invigilation system should also be in place in order to prevent corruption from taking place which endangers patients’ lives every day. The existing funds arriving from the Centre are arguably enough for the creation and maintenance of an efficient maternity care system. The focus, therefore, should be on ensuring that the funds received from the Centre are not misappropriated and utilized in an efficient and time-bound manner to employ trained and competent professionals and properly equip the district and sub-district level hospitals with the necessary mechanisms to handle major medical complications and provide proper maternity and child care facilities in the areas dominated by the tribal population. An efficient mechanism must also be adopted to raise awareness about the centrally sponsored schemes that promise to provide expectant mothers and their infants the care and social security that they rightfully deserve.

J&K will realize the dream of having a robust maternity and child care system only through the coordinated and sincere efforts of both government and the general public.

References

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