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CHAPTER 2

Maternal and Child Health Services in the Postcolonial Era

Having described the colonial context in which the professionalization of obstetrics emerged in tandem with a resigned acceptance of midwifery, I now move quickly through time to the policies and programs of the twentieth century which have informed the structure of public MCH services throughout much of the postcolonial era. In this descriptive chapter I hope to provide a general sketch first of the official structures of health care in India and in Tamil Nadu and then of the actual landscape of MCH care in Kaanathur-Reddikuppam and Nochikuppam. This chapter is intended to provide a basic framework through which to understand the more ethnographically and theoretically engaged chapters which follow. (See Appendix II for an outline of the official structures of rural and urban MCH institutions and practitioners in Tamil Nadu for 1995 that are described in this chapter.)

THE OFFICIAL STRUCTURE: THE BHORE COMMITTEE REPORT

A four-volume report by the colonial government’s Health Survey and Development Committee was published in 1946, known as the “Bhore Committee Report” (Government of India 1946) after the chair of the committee, Sir Joseph Bhore. This committee drew heavily on the recommendations of the Indian National Congress’s National Planning Committee, which was established under Jawaharlal Nehru’s guidance. The Bhore Committee Report attempted to analyze the state of health care in India and to make recommendations for the improvement of health care services in India overall.¹ Drawn up on the eve of India’s independence in 1947, the Bhore Committee Report became the template for the structure of health care services in India in the postcolonial era, as reflected in the postcolonial government of India’s Five-Year Plans. The actual implementation of the institutional structures recommended in the report were initiated ten years following its submission. Many of the basic elements of this structure remain in place today.

The Bhore Committee Report called for the establishment of a socialist system of health care, emphasizing public health services and preventative medicine for the rural poor. Madras Presidency had been the first presidency to pass a Public Health Act in 1939, which put the responsibility for the provision of public health services, including maternal and child health, in the hands of the state. With the Bhore Committee Report, public health became the responsibility of the national government, although the implementation remained in the hands of the individual states. The model envisioned in the Bhore Committee Report was a three-tiered referral system, with primary health care services emphasizing preventative care available in primary health centers (PHCs) at the village level,² secondary curative services available at the district level, and tertiary services available in the urban centers, often attached to medical teaching and research institutions. Rural women seeking allopathic services during childbirth were encouraged and expected to use this three-tiered system according to their needs.

Following the Victoria Fund’s approach, the Bhore Committee Report also posited that the hereditary dais would inevitably remain central to the care of Indian women during childbirth, at least in the short term. The report, therefore, supported efforts to provide basic training to the hereditary dais rather than trying to replace them with a new cadre of midwives. Government support of such dai-training programs continued in independent India, and these programs were included in the government of India’s Five-Year Plans.

In addition to Madras Presidency’s early move to take responsibility for public health services in general, the Madras Presidency’s Department of Public Health also took an active role in overseeing the training and deployment of auxiliary health workers specializing in MCH care, known officially as “health visitors.” In 1938 the Department of Public Health took over these responsibilities from preexisting voluntary organizations such as the India Red Cross Society. Based on a model borrowed from Britain, health visitors were women who were to be trained in such subjects as elementary physiology, home nursing and first aid, household management and dietetics, maternity and child hygiene, and character training and mental hygiene.³ The Bhore Committee Report envisioned that, after completing their training, these health visitors would be appointed to medical institutions serving women and conduct outreach work in the communities surrounding these institutions to provide basic health services and educate others on the merits of these topics.

It was, however, an ongoing struggle to make the establishment of such a cadre of auxiliary health workers a basic structure of the postcolonial public health service sector. Ever since the implementation of the three-tiered primary-health-based structure, state governments have faced great difficulties in convincing urban-trained doctors to take up employment in rural hospitals. This made it politically difficult to establish a cadre of auxiliary medical staff attached to primary health centers who could serve as community health workers, since some felt that the presence of such auxiliary health workers would be an impediment to sincere efforts to staff the PHCs with more-qualified doctors. There were also concerns that these auxiliary workers would begin to work independently of the doctors’ supervision, and that the rural poor would thus be served by under-qualified “quacks.”⁴

By the mid-1970s, however, the multipurpose-health-worker (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 used—of members of the community. They reported this information to the MPHW in the mini-health-center. In addition, lay firstaiders could provide basic first aid care to people at home. Each mini-health-center was staffed by a male and female MPHW. The training for MPHWs was one year for male MPHWs and eighteen months for female MPHWs. The extra six months for female MPHWs was to provide training in MCH care. The VHS doctors working in the rural areas generally worked for VHS only on a part-time basis, making occasional visits to the various mini-health-centers to check up on the centers’ status.

The mini-health-center in Kaanathur-Redikuppam consisted of a small cement-block room with a desk which was cluttered with vials of different sorts of medicines and packets of pills. And there were two metal fold-up chairs—one for the MPHW and one for the patient. Attached to the room was a tiny waiting area which was open to the outside road, though partially protected by a fence made of rough sticks and thatch. There was also a rubbish pile, haphazardly dumped to the side of this waiting area, which contained, among other things, medicine wrappers and bottles and used syringes that attracted a swarm of flies. I found myself spending quite a bit of time in this dingy waiting room since the open hours for this mini-health-center were fairly inconsistent. But the male or female MPHW in charge did usually show up, and many people from the area did come to seek his or her advice and get treatment for all sorts of ailments.

In Kaanathur-Reddikuppam, Muttamma’s own son was the male MPHW during the time of my research. The female MPHW who was attached to this center when I began my research left VHS halfway through the year and established her own private practice seeing deliveries in her own home in a town about forty-five minutes away by bus from Kaanathur-Redikuppam. She was replaced by another female MPHW who also had to travel by bus to come to the center, which meant that she was not available for emergency care during off hours. The female MPHWs were trained to conduct deliveries in homes if it became absolutely necessary that they do so. But their mandate, while working for VHS, was to educate women about prenatal care, deliveries, and postnatal care, and refer them to a hospital for deliveries. The headquarters of VHS only opened up its own obstetrics ward in 1994; the MPHWs were just beginning to refer women to that hospital for deliveries. Although the VHS female MPHW was an important source of information regarding MCH care in the vicinity, and she provided some pre- and postnatal care, she rarely in fact conducted deliveries herself.

Like the female MPHW who left to start her own practice conducting deliveries in another town, Shahida had been trained as a MPHW at VHS. After working for VHS and other voluntary health organizations in other regions of Tamil Nadu, she and her husband had come to Kaanathur-Reddikuppam in 1994 to establish their own clinic, and she was privately conducting home deliveries in the area. She and her husband were living in a room attached to the home of Murugesan (the panchayat president described in the Introduction), which was on the southern end of the main street of Kaanathur-Reddikuppam. They had set up their clinic in that house. Although Shahida would see prenatal and postpartum patients in the clinic if they came to visit her, she conducted all her deliveries in the homes of the laboring women.

Shahida’s arrival had created a certain amount of resentment on the part of Chellamma, a fifty-five-year-old maruttuvacci who had been conducting home deliveries in the area for over twenty-five years. Chellamma’s home was on a small path just off the main road near the mini-health-center. Like most hereditary maruttuvaccis, Chellamma had learned how to conduct deliveries through observation and apprenticeship at home rather than through any formal dai-training program. Karpagam, who lived in a thatched house off the open road leading from Kaanathur to Reddikuppam, had undergone a dai-training course at the Kelambakkam PHC in 1990 and also conducted home deliveries on occasion. This was not a hereditary profession for her. She was, however, quite critical of the training she had received since it was very time consuming and did not adequately compensate her for loss of pay due to missed work. She was also bitter that her clients did not pay her adequately and so she found herself seeing fewer and fewer home deliveries over the years. I have met some hereditary midwives in Tamil Nadu who complained that after they had gone through the dai-training programs their clients were more hesitant to pay them than they had been prior to the training, since these clients believed that the midwives were now receiving regular payment from the government.

For both Chellamma and Karpagam, the delivery work was very much part-time. Chellamma had worked most of her life as an agricultural laborer, and Karpagam was working as a laborer on construction sites.⁸ Neither of these women provided prenatal care. They came only at the time of the delivery. Chellamma would also come for postpartum visits to bathe the baby and prepare postpartum medicines, but Karpagam did not provide these services.

There was one pharmacy in Kaanathur-Reddikuppam, which was located on the main road in the middle of all the shops. This pharmacy was run by a man whom most people referred to as a “doctor.” He had MPHW training and had also taken a three-year course in Siddha medicine. When people asked this pharmacist what he recommended in terms of prenatal and postpartum care for mothers, he tried to encourage them to take Siddha medicines.⁹ But he complained that people no longer had the patience required for Siddha medicines to really take effect, and they were increasingly demanding allopathic medicines, especially injections, for immediate results. It was because of this attitude, he said, that he was increasingly being summoned to accompany Chellamma to deliveries to give vitamin B₁₂ injections to speed up labor. The pharmacist also occasionally gave mothers and newborns immunization shots. The pharmacist’s shop was a private enterprise, so patients paid a fee for the medicines and services he provided.

In addition to the care provided by the VHS workers, Shahida, Chellama, Karpagam, and the pharmacist, women in the area could also get some government-provided prenatal and postpartum care at the local balwadis (day-care centers), which were run by the government’s Integrated Child Development Services (ICDS). ICDS had become a national program throughout India, but it was modeled on a scheme initiated in Tamil Nadu during M. G. Ramachandran’s term as chief minister in the 1980s. In Tamil Nadu, this program was often called by its original name, the Chief Minister’s Noon Meals Scheme. This program had helped to establish balwadis in low-income communities throughout the state. The balwadis served as free day-care centers for children ages two to five and provided them with free lunches that were supposed to include rice, dal, soya flour, vegetables, and occasionally eggs. In addition, at these balwadis, packets of dried nutritious food (in Tamil referred to as cattu uavu māvu) were distributed to pregnant and lactating mothers and to children ages six months to two years. This cattu uavu māvu contained a mixture of wheat, ragi, soya, fried gram, and jaggery. In rural areas, such as Kaanathur-Reddikuppam, these balwadis also served as sites where VHNs from the PHC would come on a monthly basis to provide pre- and postnatal care, including immunizations, to pregnant women and postpartum mothers and their children. The ICDS in Reddikuppam was established in 1987, also during M. G. Ramachandran’s term as chief minister. The ICDS in Kaanathur was established in 1994.

In addition to the above-mentioned MCH services for women within Kaanathur-Reddikuppam itself, services were also provided by various hospitals outside of Kaanathur-Reddikuppam. The PHC which serviced Kaanathur-Reddikuppam was located in the town of Kelambakkam. Very few women from this area chose to go to the Kelambakkam PHC just for their deliveries. This was partly due to the distance. As the crow flies, Kelambakkam was quite close. But the route there from Kaanathur-Reddikuppam was indirect and arduous. People would first take a bus going south to Kovalam and then get an auto-rickshaw or van to take them on a long dirt road riddled with potholes through the paddy fields back up to Kelambakkam, which lay on the east side of the canal. The trip by this route took about forty-five minutes. Most felt that travel to Madras was much more convenient even though it took a bit longer. Furthermore, they felt that the quality of care in the larger “government hospitals” in Madras was superior to that of the PHC. The “government hospitals” had emergency care for such things as cesareans, whereas the PHC did not. Those who did go to Kelambakkam for their deliveries only did so if they were planning to undergo sterilization following their delivery. Because the PHC in Kelambakkam was the central PHC for the entire Thirupoorur development block, there were more beds there than in most PHCs.

The other main option for women seeking care for deliveries in public hospitals was to go to the Kasthurba Gandhi Hospital in Madras. This large “government hospital” was usually referred to as “Gosha Hospital” because of its previous name as the Victoria Hospital for Caste and Gosha Women during the colonial era. The direct journey to Kasthurba Gandhi Hospital from Kaanathur-Reddikuppam by auto-rickshaw or van was approximately 20 km. and took about one hour. Many could not afford the expense of such private transportation (Rs. 150), however, and instead had to take two buses (costing a total of less than Rs. 10) to travel to Kasthurba Gandhi Hospital, thereby making the trip one-and-a-half-hours long. Some women from Kaanathur-Reddikuppam who were planning to deliver at Kasthurba Gandhi Hospital would go to the hospital in advance of their labor and, if there was room, stay in the prenatal ward until their labor began. Those who had female relatives (usually on their side of the family rather than their husband’s) living in Madras would go and stay with them prior to their due date so that they could reach the hospital immediately once labor pains began.