So far a lot of thought has gone into this blog, and not a lot of typing. So here goes: a day by day account of our trip to India with Save the Children.
Part 1. Day 1, morning. Rajasthan State.
Our group departed Jaipur for Kaliptan in Tonk district of Rajasthan. The first visit planned for today was to meet Save the Children India (SCI) partner NGO & visita primary health care centre. Later we were to visit the District level hospital, meet Anganwadi workers at carrying out their daily duties then liaise with religious leaders making a difference in their areas.
As we weaved our way between the most elaborately decorated trucks, errant cows on the road and rickshaws Hemant the Indian SCI staff member who was leading our visits gave us an overview of the situation for the children of Tonk and Rajasthan in general. In the whole state 48% of children are malnourished, and in Tonk district this rises to a staggering 70%. As such, a large proportion of SCI work is focussed on nutrition, hygiene and breastfeeding. For India’s infants already facing a 1:20 chance of dying before they reach their first birthday exclusive breastfeeding can be a real lifesaver, yet only 46% of India’s babies are exclusively breastfed. Hemant explained that this is due in part to the cultural practice of giving pre-lacteal feeds. These are feeds, known locally as ghutti, are traditionally given to the baby instead of breastmilk which they believe cannot be given until the first prayer – the Azan, is announced from the Masjids in the Mosque. Ghutti can be honey water, cows milk or water with herbs added. For the newborn this means they are deprived of the many benefits of its mothers colostrum – sterile, nutritious and protective, and for the mother this means she often does not go on to produce enough milk as the crucial early feeds fail to stimulate her to provide the baby sufficient milk. The Unicef Baby friendly Initiative recommends the baby feed from its mother within one hour of birth. For most babies in Rajasthan this may not happen for days with dire consequences for mother and baby.
As we passed (precariously overtook) many of the lavishly decorated truck en route Hemant went on to explain how HIV and STIs are a major problem there as the truckers use sex workers and ‘bar girls’, something I had also witnessed in Cambodia. In some families a child is even kept for this ‘profession’ as the financial remunerations can be great. The health consequences however are devastating. Men pay more when a condom is not used and hence HIV and other sexually transmitted diseases are rife in these groups. Alcohol abuse can result as the men use liquor to gain ‘strength’ and the girls use it in order to cope and give them ‘energy for their work’. With so many clients they rely on alcohol to see them through their duties and nutritious food, condom use and healthcare becomes less of a priority with the obvious consequences.
As we approached our destination we crossed a vast river on the fly-over, the main river and water source for the area. It was parched and completely bone dry.
On our arrival in Kalipaltan we met with SCI local implementing partners CECODECON. They are a health and sanitation NGO, and we could not have received a warmer welcome – coffee, flower garlands, red powder bindis were etched on our foreheads and we were all introduced to each other. They took us to visit a primary healthcare facility in their town. One Doctor is based here, responsible for a catchment population of 40,000 people. The place was heaving; he sees around 200 people every day and is only supported by 2 other ancillary staff. Whilst it was fantastic to see that the local community trust and utilise the services there it was humbling to see such a dedicated doctor work so hard to serve his community. They also provide DOTS (directly observed treatment, short course) for tuberculosis, and have seen an incredible 85% coverage. He explained to us about his hardships working there. In 2011 India initiated a free drug policy for about 175 medications, yet one of the biggest problems he faces is replenishment of his supplies from the state health department. Malnutrition is one of the biggest health concerns for his community, reflected in the figures mentioned above for Rajasthan and Tonk district. This again highlighted the importance of promoting exclusive breastfeeding and growth monitoring in improving the health of children here. CECODECON with support from Save the Children India largely focus on these issues, and have implemented the use of community score cards to track progress in these areas and use results to steer their programs, achievements they were proud to show us in their offices displayed on their wall charts.
From there we went on to Sahadat District hospital, Tonk District. A free government facility led by the Chief Medical Officer who explained to us the services that are provided there. It is a 200 bedded tertiary level hospital serving a staggering 1.4 million. They are awaiting the build of a 100 bedded maternity hospital in the near future. Here they see 1000 outpatients per day, conduct 20 births per day and have 2 operating/surgical rooms. Also here is a malnutrition ward, special care baby unit and family planning, STI services. The staff include 10 midwives, 29 female nurses and 3 obstetricians. We asked the CEO what were the main constraints he faces at this hospital. He stated there are not enough staff for the number of patients, and the salary is poor, which in turn detracts staff from seeking employment here and impacts greatly on staff retention. Understandable. Where I work in the UK we conduct about 12 births per day and have on duty at least 12-15 midwives per shift with 3 doctors. How they manage at this hospital with only 10 midwives on their books and 3 doctors for maternity for 24 hours a day service provision I can’t imagine. A worrying example of how this could affect safe intrapartum care became evident to me whilst visiting the special care baby unit. Here there were about 4-5 newborn babies in quite a well looked after ward with power and medicines, yet there were no incubators. Instead each baby was on a resuscitaire trolley of the kind we us in the UK which is only for very short term use immediately after the baby is born if it needs oxygen, an overhead heater and suction for example. But here these were being used as makeshift incubators, with the overhead heaters used continuously and oxygen being delivered via head-boxes instead. I enquired as to why these babies had been admitted and it seems that at least 2 that I saw were there due to prolonged labour and birth asphyxia. I assumed then that these babies had been transferred in from the surrounding villages yet sadly these labours had been managed from the outset within the hospital. I immediately began to question the level of care that was being provided at this tertiary facility where labour had been allowed to become prolonged and birth asphyxia had ensued undetected. Was there any difference then in labouring at home or in the hospital if the outcome was going to be the same? For a nation striving to promote 100% ‘institutional deliveries’ I wondered if they were really ready for this with a lack of staff and equipment. As we did not get to see the labour ward at this hospital I kept my judgment reserved as we were to visit a maternity hospital in Delhi where I would see for myself the services offered. For one baby there attached to an IV and oxygen, the nasal flaring, sternal recession, palid colour, and very poor tone on day 3 following birth I wondered how long it could realistically remain on that makeshift incubator with no prospect of any further advanced treatment. Even here he had not been offered any of its mothers milk.
Next time: Day 1 afternoon, visit to an Anganwadi and meeting the religious leaders making a difference in their communities.