Maternal Death

In Godda District, Jharkhand

JHARKHAND FACT-FINDING REPORT

INTRODUCTION

Maternal health in India is in a state of crisis, particularly in Jharkhand. Outside of Africa, India

has one of the highest maternal mortality rates (MMR) in the world. An Indian woman dies in

childbirth every eight minutes; her lifetime risk of maternal death is one out of seventy.1 Rural

communities and minority women are especially vulnerable to maternal complications and

mortality. In response its abysmal MMR, the Indian Government has created myriad schemes to

address the factors that contribute to maternal death.

Godda district is a rural, tribal district in northeastern Jharkhand. Its total population is 1,311,382

and its literacy rate is 57.68%.2 In this context, a team of health activists went to the Godda

district of Jharkhand to investigate the implementation of National Rural Health Mission

(NRHM), National Maternal Benefit Scheme (NMBS), Janani Suraksha Yojana (JSY), and

Integrated Child Development Scheme (ICDS) in villages served by the Poreyhat and

Sunderpahari Community Health Centers (CHCs).

The high number of maternal and infant deaths in the district demonstrates that public health

authorities have not effectively implemented these schemes. The fact-finders concentrated their

work in two blocks: Sunderpaharj and Poraiyahat. There are on average 3,400 births per year in

these two blocks of Godda District. From April to December 2011 health officials recorded 21

deaths for 2,550 births. The MMR for this period works out to 824, a rate on par with Chad, the

country with the sixth highest MMR in the world.

These reports of Maternal Deaths have been sent to the Civil Secretary, the Deputy Director, and

the State Mission Director of the NRHM. However, the government has taken few to reduce the

MMR. In response to previous concerns about maternal health care in Jharkhand, the

government established a free ambulance service in April 2011. The ambulances, however, are

private cars and do not have medical equipment or trained medical staff. Moreover, local

1 Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and the World Bank. (WHO: 2007)

Available online at: www.who.int/whosis/mme_2005.pdf 2 Indian Census 2011.

facilities frequently refer women to Bhagalpur Medical College in Bihar, the neighboring state.

Government ambulances will not take patients across state lines. Accordingly, families pay

private drivers to travel over 70 kilometers (over two hours) during medical emergencies.

Sadar District Hospital in Godda serves these blocks. It is designated as a First Referral Unit

(FRU), but the fact-finding team found that doctors frequently refer women in labor to other

hospitals in Bhagalpur. The District Hospital completed its first Cesarean delivery (C-section) in

January 2012 because the delivering woman had local health activists accompany her to the

hospital. All the gynaecologists employed at the district hospital have private clinics where they

regularly perform C-sections.

Despite being a First Referral Unit, the Sadar Hospital in Godda does not have a blood bank. At

the local level, CHCs and PHCs in Poraiyahat and Sunderpahari blocks do not have blood

supplies. Women who need blood transfusions must obtain donations at the time of the

emergency or travel 70 kilometers across state lines to Bhagalpur, Bihar. Before Jharkhand

became an official state in 2000, the government planned to establish a blood bank in Godda, but

today, the National Polio Service Office and doctors’ restrooms are housed in the designated

space.

The fact-finding team assessed the overall maternal health situation and spoke to women and

families about their experiences with maternal mortality.

Methodology

In the absence of meaningful maternal mortality death audits, Jharkhand health activists collect

information on maternal deaths. On 26 January through to 29 January 2012 a team of health

activists visited several families who lost a family member in childbirth. The team also spoke

with local ASHAs about their views and observations on maternal death in the district. To gain a

more complete picture of the situation in Godda, the team visited several health facilities in

Godda district. The fact-finders interviewed an ANM at the Sunderpahari CHC.

Implementation of NRHM under Indian Public Health Standards Guidelines

Implementation of NRHM was uniformly very poor in the villages visited. The goal of NRHM is

“to improve the availability of and access to quality healthcare by people, especially those

residing in rural areas, the poor, women and children.”3

Through interviews with health care providers, the fact-finders examined compliance with

NRHM guarantees. The chart outlines the team’s findings:

Entitlement Level of Implementation

At least one ANM present at the sub centre No. None of the villages visited had an ANM

who stayed at the sub health centre.

Village Health and Sanitation Committee No. None of the villagers interviewed knew of

such committee in their village.

ASHAs have a drug kit No. Of the four ASHAs from various villages

interviewed none had ever been given a drug

kit.

Minimum of 4 antenatal checkups done by the

ANM

No. None of the women in the villages

surveyed reported seeing or having an

antenatal checkup from and ANM. The ANMs

interviewed never visited pregnant women in

their homes.

Registration of pregnancy No. ASHA workers and family members

reported that no registration of pregnancies was

being done.

Iron and Folic Acid (IFA) supplementation Sometimes. Provision of IFA supplementation

3 NRHM official website, Ministry of Health and Family Welfare, Government of India,

http://mohfw.nic.in/NRHM.htm.

given from 12 weeks was reported in a small minority of cases.

Generally, IFA tablets had not been distributed

over the past two years.

Minimum laboratory investigations like

Hemoglobin, urine albumen and sugar.

No. No reports of lab testing in the villages

visited.

Identification of High Risk Pregnancies for

Referral and Counseling

No. Since ANMs do not perform check-ups

and examinations at the sub centre level high-

risk pregnancies remain unidentified. This is an

especially egregious oversight given that

multiple women reported giving birth to still-

born twins and many of the maternal deaths

occurred after abnormal presentation of the

baby.

A minimum of 2 post-partum home visits after

the child was born.

No. This was never reported to have happened.

CHC is linked to a district blood bank No. There is no district blood bank.

Essential and Emergency Obstetric

Care including surgical interventions

like Caesarean Sections and other

Medical interventions.

Sometimes. The CHC has only preformed one

Cesarean section and both the CHCs in

Sunderpahari and Poreyhat regularly refer

women who need C-sections

24 hour delivery services provided at the PHC No. Women in labor have been turned away

from open PHCs.

Skilled attendance at all births Sometimes. Many women deliver at home

without skilled attendants.

Conditions of the Sub Health Centres

Many sub-centres designated to this district do not exist. The fact-finding team found that in

many cases, the SHC building had not been constructed or that the constructed building was

completely empty. For example, Dungabara should have a SHC; instead the village has an

empty, broken down building. This sub-centre is supposed to serve at least two villages. The

sub-centre in Jogi Marna has not been constructed. Half of the SHC designated building in

Beldang serves as some sort of cow shed. The other side of the building has some materials and

posters but the ANM cannot work out of the building. Without existing or safe facilities, the

ANM’s operate out of ICDS/Anganwadi buildings.

Sub centre at Beldang

Rooms at the health sub centre

Conditions of the PHC in Dumru

Dumru PHC.

The fact-finding team visited a PHC in Dumru, which was locked and closed at the time of the

visit in the afternoon of 26 January 2011. The premises looked abandoned and dirty and there

were syringes lying in a pile of trash less than 10 meters from the PHC. Trash and standing

water surrounded the water pump. Locals reported that the PHC does on average 2-3 deliveries a

year.

Locked door at Dumru PHC.

Bathroom at Dumru PHC.

Discarded syringes just outside Dumru PHC.

Standing water and trash around Dumru PHC’s water pump.

Conditions at the CHC

Sunderpahari CHC.

The fact-finding team visited the CHC in Sunderpahari on 29 January 2012 and spoke with an

ANM and the medicine stock keeper. In the maternity ward, the team observed two dirty metal

tables and a rusty oxygen tank. The beds were covered with dirty, stained, and torn sheets and

old rubber. There were dirty gloves on the sink and no light bulbs in the room. There was a

kerosene lamp on the table indicating that this may have been used instead of electric lighting.

Maternity ward at Sunderpahari CHC.

Maternity ward at Sunderpahari CHC.

Maternity ward at Sunderpahari CHC.

Maternity ward at Sunderpahari CHC.

Trash at the maternity ward at Sunderpahari CHC

Standing water at the maternity ward at Sunderpahari CHC

The fact-finding team also spoke with an ANM, who said that most of the facility’s 28-32

deliveries per month are normal. She said that occasionally the CHC refers women to larger

hospitals if the umbilical cord is wrapped around the baby’s neck or if the baby is in the breech

position. The fact-finders asked the ANM if she though this region had a high MMR and she said

that regular ANM village visits keep the rate low.

When asked about government schemes, she reported that IFA tablets and JSY benefits were

distributed exclusively for hospital deliveries. She said that NMBS money is not dispersed.

When asked what programs are available for low weight babies, the ANM told fact-finders that

the CHC has never delivered an underweight baby.

The fact finders examined the 2009 – 2011 birth registry. As the ANM reported, almost all

deliveries were normal, and few referrals were recorded. The fact finders looked up the record

of Talamoy Baskia, a woman who had recently died shortly after giving birth. The birth was

recorded as normal and the baby was recorded as weighing 2.5 kilograms at birth. Talamoy died

hours after leaving the CHC and her son, who is now five months old, only weighs 3 kilograms.

Implementation of NMBS

Under NMBS, women receive Rs. 500, two or three months before delivery. The government

did not provide this money in any of the maternal mortality cases investigated in this report.

Additionally, villagers present at these interviews said they had never heard of this money being

distributed.

Implementation of JSY

Likewise, government health facilities have not implemented JSY in the villages. Under JSY

rural women receive Rs. 1400 for an institutional delivery and Rs. 500 for a home delivery. In

the home delivery cases explored in this report, not a single woman got Rs. 500. Of the

institutional deliveries, one woman received her Rs. 1400 payment.

An ANM at the CHC told fact finders that JSY is only to women with BPL cards after their first

and second pregnancies. The Delhi High Court has stated that JSY money should be given to

women irrespective of the number of births they have had.

Implementation of ICDS

ICDS is not properly administered in many villages. Rations are not available for children under

the age of three and most ICDS do not provide rations for pregnant women or adolescent girls.

Villagers that do not have a village-specific ICDS do not know which ICDS they are attached to

and never receive their benefits. This is especially dangerous since many ICDS function as

pseudo-sub health centres. ANMs will visit a few times a week to administer shots to pregnant

women. Below is a table showing the villages and the levels of ICDS benefits families reported.

Village Name Is there an Do children Do children Do Pregnant Do Adolescent

ICDS

Centre in

the Village

under the age

of 3 receive

rations?

3-6 receive

rations?

and

Lactating

Women

receive

rations?

Girls receive

rations?

Barmasia No No No No No

Bokrabund Yes No ICDS only

allocated

enough rations

for 36

household

though there

are 110 homes

in the village

No

Tusaria Yes No Yes Yes Yes

Tilabad Yes No Yes Yes Yes

Sakrifulva Yes No Yes Sometimes No

Beddam Yes No Yes Yes No

Other Infrastructure Challenges and Maternal Health

Many of the roads in the area are unpaved and in poor condition. Since many of the sub centres

are non-functional and the PHCs are often closed, women travel long distances to reach the

CHCs in Poreyhart and Sunderpahari. The government recently implemented an ambulance

program to combat travel-related maternal mortality. However, on ambulances cannot always

travel on the unpaved roads at night. Travel presents a major roadblock to institutional deliveries.

Road outside PHC in Dumru.

Water presents another significant challenge. Many villages use open wells for water because

hand pumps have fallen into disrepair. The village of Barmasia, for example, has five broken

pumps and the local leaders have not taken steps to remedy the problem. Lack of access to clean

water increases the risk of waterborne diseases, which are especially dangerous for pregnant

women whose bodies are already under the stress of pregnancy.

Maternal Deaths

Without access to health care or government benefits, women in this district have low health

indicators. Although Jharkhand reports an official MMR of 278 in its annual health survey, the

fact-finder’s data from Godda District shows an MMR of 824. This was calculated for the

period between April and December 2011, when Godda District recorded 21 maternal deaths. In

January and early February 2012, three more women died in childbirth in Godda District.

According to the District Health Action Plan for Godda there should be 16 sub-centres in

Sunderpahari and in 30 sub-centres in Poreyhat. In reality, the vast majority of these facilities

are nonoperational and understaffed.

The lack of health infrastructure in Sunderpahari and Poreyhat blocks is a clear contributor to the

high number of maternal deaths. Because health care at the most basic level does not function,

women in Sunderpahari and Poreyhat do not have access to health care before, during, or after

pregnancy. Maternal mortality is entirely preventable. Reports from the World Health

Organization (WHO), UNICEF, and World Bank all agree that at least 80% of India’s maternal

deaths could be prevented if women simply had access to essential maternal and basic health-

care services.4 The National Rural Health Mission in Jharkhand has utterly failed the women and

families of Sunderpahari and Poreyhat.

Narratives

1. Munika Hebrom, age 22

Munika Hembro, wife of Kushal Soren from Kusmaha, died at the age of 22 on 16 December 2011.

Kusmaha is 22 km from the CHC in Sundarpahari and 5 km from the nearest PHC and sub-centre.

4 Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal

mortality and morbidity and human rights (excerpts) A/HRC/14/39

A mission hospital in Godda had been treating Munika for pulmonary tuberculosis since 2008. Her family

was concerned about her third pregnancy, because she tuberculosis-related complications during second

pregnancy. Throughout her final pregnancy, she had a cough and sometimes produced sputum with blood.

Munika did not receive antenatal care during her pregnancy. In fact, no one knew Munika was pregnant

until the end of her first trimester. The ANM in the village gives tetanus toxoid injections at the ICDS

centre, but does not visit individual homes.

On 15 December 2011 Munika delivered a premature baby at home. The baby died five minutes after

birth. Following delivery, Munika complained of extreme weakness, restlessness and anxiety.

On the morning of 16 December 2011, Munika’s husband called a local practitioner for an examination.

The local practitioner gave Munika some injections, but her condition did not improve. An hour later, her

family decided to call for medical assistance but Munika died before her family could contact the

ambulance.

Narrative as reported by the deceased’s mother-in-law and sister-in-law at Kusmaha.

2. Shanti Marandi, age 21

Shanti Marandi, wife of Devilal Murmu, lived in Jitpur (Baru Tola). Jitpur is 34 kilometres from the

District Head Quarters, 14 kilometres from the nearest CHC and 7 kilometres from the nearest sub centre.

At age 21, Shanti was pregnant with her first child. She had limited antenatal care; the local ANM

administered two tetanus toxoid injections and three months into her pregnancy she was treated for a

fever. She was not examined by the ANM and never received IFA tablets. Shanti received take home

rations twice.

Between her 8th and 9th month of pregnancy Shanti reported body pains and headaches. On 29 December

2011 Shanti told her family that she had intense abdominal pain. In the evening her husband called the

ambulance of Jindal Steel & Power Ltd. (JSPL). The ambulance took her to a First Referral Unit, Sadar

Hospital in Godda.

After an examination at the hospital, Shanti received medicines and an intravenous drip. At around 2:30

in the morning on 30 December 2011 she was referred to the Medical College at Bhagalpur in Bihar, 70

kilometres away from Godda. The ambulance took her to Bhagalpur at 6:00 a.m. Shanti died a few hours

later after she reached the Medical College.

Narrative as reported by the deceased’s husband at Jitpur

3. Gunna Marandi, age 20

Gunna Marandi, wife of Bisnath Besra, was a resident of Pharpur (Badra). She died from pregnancy-

related complications at the age of 20 during her first pregnancy.

Badra is 27 kilometres from the District Head Quarters, 7 kilometres from the nearest CHC and 3 km

from a sub centre.

During her pregnancy Gunna received two tetanus toxoid injections from the ANM. Her family said she

reported feeling weak and frail in September 2011. Other than undergoing treatment for a fever she did

not report any illnesses during her pregnancy.

On 21 December 2011, Gunna went to her paternal home at Niponia (Mohli Tola), Godda, 17 km from

her village. A week after making the trip she felt uneasy and breathless. The family suspected that the

baby died and they called a private practitioner who gave her injections. Her condition did not improve

and she developed mouth ulcers and stopped eating. She was then taken to a private clinic at Godda

where she received additional injections and an intravenous drip.

Gunna’s blood tests were normal and she was discharged. She returned home and fell into semi-

consciousness. She delivered a stillborn baby at 8 am on 31 December 2011 and died later that day at

around 2 pm.

4. Shamina Khatun

Shamima Khatun, wife of Muzaffar Ansari, lived in Khanwa. Shamima was 19 years old and had been

married for about 10 months. She was pregnant with her first child in January 2012.

Khanwa is located 15 km from the CHC and 42 km from the District HQ.

Her family told fact-finders that Khanwa had always been frail and thin, but that her pregnancy had

advanced without complaint.

During her pregnancy she had 4 antenatal checkups at a private clinic in Godda. During her eighth month

of pregnancy Shamina was involved in a minor motor cycle accident en route the private clinic. The clinic

assured Shamina’s family that she would be fine.

On 16 January 2012, during her ninth month of pregnancy, Shamina fell unconscious around 2:30 a.m. A

hired vehicle transported her to the CHC at Mahagama. She arrived at the CHC at approximately 4 a.m.

The doctor examined her and gave her injections.

Her family reported seeing her in convulsions. The next afternoon, Shamina had recovered. The doctor

told the family that delivery would initiate within 48 hours. Around midnight on 19 January 2012 labour

pains started. The nurse administered injections and took her to the labour room. By 1:10 a.m. Shamina

delivered a baby. The family said that the delivery was normal.

Shamina was then transferred to the recovery room. After 10 minutes in the recovery room Shamina

wanted to urinate but did not have the strength to go the toilet and come back. Her family said she

reported anxiety and restlessness. Shamina also began to bleed heavily. The doctor put her on an

intravenous drip, but Shamina requested the nurse to stop the drip. She began to convulse.

The doctor told the family that Shamina required a blood transfusion and a transfer to Bhagalpur Medical

College across state lines in Bihar. The Medical College is 80km from the CHC.

While the family was arranging to hire a vehicle Shamina drifted in and out of consciousness. The family

hired a vehicle to take her to Bihar. She died on 19 January 2012 as the CHC staff was moving her into

the vehicle. The doctor told the family that she died of eclampsia.

The family spent around Rs. 4,000 on vehicles and medicines during Shamina’s pregnancy. Shamina’s

baby survived and is being looked after by her elder sister.

As reported by Shamima’s father Md Haffasuddin

5. Madhu Hansda age 35

Madhu Hansda, wife of Kushal Munda, lived in Dharmodhi. Dharmodih is 5km from the District Head

Quarters.

Madhu’s first pregnancy at the Mission Hospital in Godda was normal. Throughout much of her second

pregnancy she worked as a Station Master at the Dhanbad Railway Station. On 4 December 2011 Madhu

went to her home village. On 7 December 2011 she began daily intravenous infusions at the Mission

Hospital in Godda.

On the evening of 10 December 2011 her condition deteriorated and the Mission Hospital referred her to

Bhagalpur Medical College in Bihar, 75 km from the Mission Hospital.

Her family took her to a nearby private clinic for a second opinion. At 8 pm on 10 December she

delivered a baby. Almost immediately after delivery, Madhu slipped into unconsciousness. She was taken

to Sadar Hospital in Godda for oxygen and was declared dead on arrival around 9 pm. Her family said her

skin looked yellow when she died.

Madhu’s child is still alive.

As reported by Madhu’s aunt.

6. Rinan Marandi age 23

Rinan Marandi, wife of Rajesh Hastah, lived Beldang. Rinan was 23 years old when she died. Beldang is

7 kms from the nearest CHC and 27 km from the District HQ.

Rinan’s first pregnancy ended in a stillbirth and her second pregnancy was normal. Rinan died from

complications related to her third pregnancy in 2011. Rinan was 22 years old.

Rinan received tetanus shots, iron supplements, and folic acid tablets from an ANM, but she did not have

a physical examination during her pregnancy. Rinan received take home rations from the ICDS.

Two and a half months into her pregnancy Rinan began periodic vomiting. In her fifth month of

pregnancy she went to Sadar Hospital in Banka, Bihar. The hospital staff gave her medicines. Later, at a

private clinic in Banka, Bihar Rinan was diagnosed with Typhoid. She visited a private clinic four times

for treatment. Her family spent at least Rs. 5,000 for these private consultations. The private clinic doctors

told her that the foetus was very weak. After the Typhoid treatment, Rinan continued to have a light fever

and vomiting.

On 4 November 2011 when Rinan was about 8.5 months pregnant, she had convulsions and fell

unconscious. The family called a local practitioner who gave her injections and put her on an IV but

Rinan’s condition did not improve. The local practitioner charged the family Rs. 4,000. The local

practitioner advised the family to seek medical assistance from a facility. The family hired a private

vehicle for Rs. 1,000 to transport Rinan to a private clinic in Godda. The private clinic examined her,

charged the family Rs. 200, and then referred them to the Bhagalpur Medical College & Hospital in

Bihar, around 70 kms away.

The family then hired another vehicle on the evening of 5 November 2011 for the trip to Bhagalpur. The

vehicle cost Rs. 1,500. The hospital staff diagnosed Rinan with Malaria and Typhoid. Rinan received an

IV and injections. The doctors told the family that Rinan was anaemic and needed blood.

Rinan did not regain consciousness and she and her child died on 8 November 2011. The Bhagalpur

Hospital charged the family Rs. 500. Rinan’s family spent another Rs. 3,000 for a private vehicle to bring

Rinan’s body back to her village.

The family mortgaged jewellery and ornaments to afford Rinan’s treatment.

Receipt for jewellery

As told by the deceased’s husband, brother-in-law and sister-in-law

7. Chandmuni Devi, age 31

Chandmuni Devi, wife of Ganesh Singh, lived in the village of Dumaria. Chandmuni was 31 years old at

the time of her death from pregnancy-related complications. She is survived by her husband and her seven

year old son.

Throughout her pregnancy Chandmuni complained of weakness, anaemia, and breathlessness. Her family

said that she often refused food and largely subsisted on rice water. During her seventh month, she had a

burning sensation in her urinary tract and severe weakness. Her husband took her to a private practitioner

in Poreyahat where she received injections, medicines, and an IV drip. She stayed in the private clinic for

two or three days. The treatment cost her family Rs. 4,000.

Chandmuni started having labour pains around nine pm on 6 June 2011. She was at her paternal home in

a village near Dumaria. Since it was night time the family had no way of procuring a vehicle. The family

called a local midwife.

The midwife found that the baby had an abnormal presentation with the leg coming out first. The midwife

had to manually remove the placenta after an hour. The family said there was no bleeding and the baby

was delivered at around 11 pm. The baby was very weak and died within a half hour of being born.

A week later, Chandmuni was still very weak and her family took her 15 kms away, to the CHC-Bousi,

Bihar by bus. She was given a preliminary examination at the CHC and had her blood pressure and

temperature checked. The hospital staff gave her injections, medicines, and an IV. She returned to

Dumaria, but she returned to Bousi when her medications ran out. The family spent Rs. 1,600 and Rs.

300 on transportation. The doctors told Chandmuni that she would have to return to the CHC a third time,

so they decided to stay with Chandmuni’s sister-in-law who lives close to Bousi.

On 27 June 2012 Chandmuni began to convulse. Her husband, Ganesh rushed to get an auto, but it was

too late, when he came back to the house, she was already dead.

8. Priyanka Marandi

Priyanka Marandi, wife of Babloo Murmu, resided in Kanijoria Tola (Salaiyya). Kanijoria is 1

km from the sub centre in Sijua and 20 kms from the CHC in Poreyahat.

Priyanka did not have antenatal care. She received one month’s ration supply during her nine

month pregnancy.

At 6 am on 10 July 2011, Priyanka had labor pains and before the family could secure a vehicle,

she delivered a stillborn baby with assistance from her in-laws. There was an abnormal

presentation in the delivery and the baby’s leg came out first. After delivery, Priyanka was

bleeding heavily and her body temperature dropped substantially. She had trouble breathing and

died at 9 am.

9. Sumati Soren, age 20

Sumati Soren, wife of Rameswar Hembrom, resided in Simaldhab.

Sumati was pregnant with her first child at the age of 20. During her pregnancy she did not have

antenatal care. The local ICDS gave out rations sporadically. Throughout her pregnancy, Sumati

received rations once and thus stopped visiting the ICDS centre where the ANM would

occasionally visit.

Eight months into her pregnancy she was taken to Krist Raja Health Centre, a mission hospital in

Godda, because of weakness and fever. At the hospital she was examined tested for Malaria,

anaemia, Widal, and venereal disease. The majority of her tests results were negative, but her

hemoglobin level was at 9.3 g/dl. Anaemia is diagnosed at hemoglobin levels less than 11 g/dl.

Her blood pressure was recorded as 100/60. In light of these results, the mission hospital gave

Sumati antibiotics, cough syrup, tetanus injections, antipyretics, iron, vitamins, and mineral

supplements. The doctors asked Sumati to come back immediately if she had complications and

to come back in one month for a routine checkup. The family spent around Rs. 1,000 on all the

tests and medicines.

Sumati left for her hometown of Amarpur, about 20 kms from her village of Simaldhab.

Amarpur is an island village that can only be accessed by boat. On 11 July 2011 Sumati

delivered at home, with a local midwife. The delivery was normal and a daughter, Sonmuni

Hembrom was born. About five days later on 16 July, Sumati had a series of convulsions. A

local practitioner was called. He administered two injections and IV fluids, which cost Rs. 800.

He advised Sumati’s family to take her to the hospital. Her husband went back to Simaldhab to

collect the necessary funds for the hospital trip. In the meantime, Sumati continued to have

convulsions and her child could not breastfeed.

On 27 July, Sumati’s husband carried her on cot to Dumaria. While her husband was negotiating

for a vehicle to Mohanpur hospital, Sumati died on the side of the road. Her daughter has been

living in Amulspray with her mother-in-law.

Narrative as told by Lilmuni Murmu, Sumati’s mother-in-law

10. Manju Murmu, age 23-25

Manju Murmu, wife of Jetal Soren, resided in the village of Sakri-Phulwar (Dumar Tola).

Manju was 23-25 years old and pregnant with her first child in April 2011. During the course of

her pregnancy she received two tetanus injections, iron/folic acid tablets at the ICDS, and take

home rations five or six times. She was never examined by an ANM.

At 8 am on 18 April 2011, Manju went into labor. Her family took her to the CHC at Poreyahat.

When she arrived at 10 am, the CHC staff gave her an injection and an IV. Manju did not feel

pain and could not push. The ANM, Surajmuni, estimated that Manju would deliver at 4 pm. The

ANM asked Manju’s family to move to the verandah. The ANM demanded Rs. 400 for her work

with Manju. The family bargained with her and reduced the amount to Rs. 300.

The ANM left Manju and her family on the veranda as a thunderstorm hit with heavy rain and

strong winds. Manju started having convulsions on the veranda. Her husband went to locate and

hire a private vehicle. Manju and her husband reached Sadar Hospital in Godda between

midnight and 2 a.m. on 19 April.

A nurse at Sadar hospital examined Manju because the doctor was unavailable. The ANM

administered injections and an IV. The family purchased these medicines from a private shop.

The family said that in the early morning of 19 April Manju went into convulsions four times.

At 10 am on 19 April the doctor referred Manju to the Medical College and Hospital located 70

kms away in Bihar. The family paid a total of Rs. 1,200 at the district hospital, Rs. 200 to an

ANM, and Rs. 1,000 for medicines.

Manju’s family could not afford the transportation to Bhagalpur so they moved her to Krist Raja

Health Centre in Godda. The doctor at the mission hospital said that Manju needed a blood

transfusion and a C-section. At about 6 pm on 19 April, Manju delivered a still-born baby. She

fell unconscious after the birth and died at around 7 am on 20 April 2011. The doctor stated that

death was caused by severe eclampsia and septicemia. Manju’s family spent around Rs. 5,000 at

the mission hospital and 1,600 on going to and from Godda.

When asked why they took her to the hospital when many women deliver at home, the family

said that they were told it was good to go to the hospital so they took her there.

Narrative as told by Manju Murmu’s mother Maharani Marundi

11. Rekha Devi, age 19

Rekha Devi w/o Parmanand Mandal, resided in the village of Bara. Bara is located about 12 kms

from the PHC in Poreyahat.

At 19, Rekha was pregnant with her first child. At 11 am on 3 May 2011, Rekha had breathing

problems. She was taken to a private practitioner at Ramgarh, about 4 kms away from her home.

The private practitioner wanted to give her an IV, but her family refused the treatment and took

her home. Later that night, at about 9 pm, the breathing problem persisted so Rekha’s family

asked the local village practitioner administer IV fluids. As soon as the IV fluids stopped, Rehka

experienced problems breathing. From 11 pm to 6 am on 4 May the family frantically scrambled

to get money for an ambulance or vehicle to the hospital.

At around 7:30 am on 4 May, Rekha arrived at Sadar Hospital in Godda. The doctors told the

family that Rekha needed a blood transfusion, but that it would be impossible at their facility.

The Sadar Hospital in Godda referred Rehka to Bhagalpur Medical Hospital and College 70 kms

away in Bihar.

The family tried to get Rekha treated at a private clinic owned by Dr. Prabha Rani, but the staff

would not admit her. At about 8:45 pm on 5 May 2011, Rekha died while on an IV and oxygen

in Sadar Hospital in Godda.

The doctors listed the official cause of death as severe anaemia, heart problems, and low blood

pressure.

12. Sanjil Soren

Sanjil Soren, wife of Sonoth Tudu, resided in Sagar Sadak Tola.

Sagar-Sadak Tola is about 10 kms from the PHC in Sunderpahari.

Sanjil was pregnant with her fourth child in 2011. Her first and third pregnancies resulted in

stillbirths. Sanjil had a three year old, Kanakalata, from her second pregnancy.

In the first week of June 2011, Sanjil went to Sadar Hospital in Godda because of head and neck

pain, fits, and swelling in her hands, legs, and face. She was treated at Sadar Hospital and

returned home feeling better.

On 6 June 2011 she went to the Sundarpahari PHC with the same symptoms, swelling, pain, and

fits. The PHC referred her to Sadar Hospital in Godda. The family borrowed money for the

transportation costs. Sadar Hospital subsequently referred Sanjil to Bhagalpur Medical College

and Hospital, a 70 km drive away.

At this point, Sanjil’s family had exhausted their personal savings on previous treatment and

transportation. They could not afford the further trip to Bhagalpur. At Sadar Hospital in Godda

the doctors gave Sanjil two IV drips and four injections. The hospital gave them the IV drip, but

her family had to purchase additional medicines from a private shop. The Godda Hospital

doctors also sent them to a sonography clinic for an ultrasound, an additional cost of Rs. 350.

Sanjil and her unborn child died two hours after reaching Sadar Hosptial.

In total the family had spent Rs. 6,300 in hiring vehicles, medicines, and diagnostics.

Narrative as told by Sonoth Tudu at Sarak Tola, Sagar on 09.06.2011.

13. Talamoy Baskey, age 20

Talamoy’s son, sister-in-law

and mother

Talamoy Baskey, wife of

Gupiram Soren, resided in Tilabad. Tilabad is located 1 to 2 km from the CHC in Sundarpahi.

Before Talamoy was married, she was diagnosed with Kala-azar. Doctors told her that she would

have to continue medication for Kala-azar after she gave birth. Talamoy had one other child.

During her second pregnancy she received 2 tetanus injections from the ANM but never had a

home visit, prenatal examination, or iron/folic acid tablets. She did receive take home rations at

the ICDS.

Towards the last month of her pregnancy, Talamoy had swelling in her legs and diarrhea. Her

neighbors said she was very weak and anemic. The neighbors also said she was averse to taking

medicines. Two to three days before giving birth she could not move and had a high fever.

At 9 am on 10 September 2011 Talamoy went into labor. The ASHA worker told fact-finders

that Talamoy complained of body pain in her legs and waist and felt weak. The ASHA worker

called the Mamta Wahan Call Centre, but no one answered. Talamoy was then taken by

motorcycle to the CHC in Sundarpahari, 1 km away.

At about 10:30 am, Talamoy delivered a baby, but she continued to feel intense pain throughout

her body. The doctors gave her two injections and the CHC staff kept her in the facility until

3:45 pm. With the doctor’s permission, her relatives took her home on the motorcycle.

Within minutes of reaching home, Talamoy began to seize. The ASHA worker phoned the

Mamta Ambulance service, but there was no response. She then tried calling the CHC in

Sunderpahari. A medical officer and other staff rushed to Talamoy’s home, but she died ten

minutes after the medical team reached her house.

Talamoy’s son, Rashik Soren, is being cared for by her sister-in-law. At five months old, Rashik

Soren appears severely malnourished and weighs less than 3kg.

Talamoy received her JSY payment, but did not receive NMBS.

Narrative as told by Talamoy Baskey’s mother and husband Gupiran Soren (pictured

above)

14. Pato Devi

Pato Devi, wife of Singeswar Yadav, resided in Jhapnibandh. Pato was pregnant with her third

child and 26 years old when she died. Pato’s second pregnancy resulted in a stillbirth. Pato also

ruptured her uterus during delivery. Doctors saved her life in an operation and told her that

another pregnancy could result in the death of the child or mother.

During her third and final pregnancy she had no complications and had visited the ANC at the

ICDS centre to receive her tetanus injections.

At 4 am on 24 October 2011, Pato reported having intense labor pains. A local practitioner came

to the house and gave Pato injections. The family saw no improvement in her condition so they

hired a vehicle for Sadar Hospital, about 20 km away. Sadar Hospital in Godda then referred her

to Mayagunj hospital, which is 70 km away, in Bhagalpur, Bihar.

Before going to Bhagalpur they consulted with another private gynaecologist in Godda who also

advised going to Mayaguni. At Mayaguni, Pato Devi received three units of blood and

medicines. Her condition, however, did not improve.

On 26 October 2011 Pato Devi delivered a stillborn child and died.

Narrative as told by Phulsaria Musomas, Pato Devi’s mother-in-law.

15. Surajmuni Hebrom, age 29

Surajmuni Hebrom, wife of Jetha Tudu, resided in the village of Barmasia.

Barmasia’s sub health centre is in Dangapara and the PHC is 6 km away in Dumbahar. Barmasia

is 26 km from the CHC in Sundarpahari.

Surajmuni was 29 years old and pregnant for the fifth time when she died. She is survived by

three living children. Surajmuni’s first born twins died from malnutrition when they were two

months old. Then she gave birth to a daughter, Makkubiti Tudu, who is now 10 years old. She

then gave birth to a son Sankar Tudu, who is 4 years old. After Sankar, Surajmuni had twins

who died a few hours after being born.

Both her son and daughter were born at home. They have not been immunized and the family has

never received food from ICDS.

During her pregnancy, Surajmuni did not have antenatal care. The nearest ICDS is in Bokrabund

but the family was unaware that this ICDS served their village. There is supposed to be a sub

centre in Dungabara, but it does not exist. Barmasia has five nonfunctional hand pumps for

water. Surajmuni did not have access to clean water during her pregnancy.

One of the five broken water pumps of Barmasia

The head of the panchayat has been told about the problem but has not fixed the hand pumps.

On 26 October, when she was two months pregnant, Surajmuni developed a fever. Two days

later, her fever had not gone down, so she contacted a local practitioner from Damruhar, 6 km

away. The local practitioner gave her some anti-malarial injections and antibiotics. She died later

that day.

Jetha, Surajmuni’s husband, was away in Sonipat, Haryana working on a building site. He has

since returned to take care of their remaining children, but he cannot work to feed the family.

Because he left his job so suddenly, he could not collect his remaining pay. He cannot leave his

children and will not be able to collect the Rs. 3,500 from Haryana.

Narrative as reported by Surajmuni’s neighbor Mongli Devi and her 10-year-old

daughter Makkubiti.

16. Bitia Murmu, age 22

Bitia Murmu, wife of Mondol Hansda, resided in Sidbank. The CHC in Poreyahat is 25 km

away.

At 22 years old, Bitia had been married for about a year and was pregnant for the first time when

she died. Bitia did not receive antenatal care because there has not been an ANM stationed in her

area for over two years.

When she was about three months pregnant she went to her home village of Makhni for a week.

On 7 October 2011, the day she returned from Makhi, Bitia had a fever. The next day she

vomited clotted blood three times. A local practitioner gave her injections and an IV. He told the

family that he thought Bitia may have Malaria. Bitia had fallen into a trance like state and was

not responding, eating, or talking. The family tried calling other practitioners and folk healers.

Ultimately they could not arrange for a vehicle to transport her to a medical facility. Bitia’s

parents were en route to her house when she died on 9 October 2011.

Her husband has since migrated to Mumbai to earn a living.

Narrative as reported by Talamoy Kisku, Bitia Murmu’s mother-in-law.

17. Phool Murmu

Phool Murmu, wife of Raja Marandi, resided in the village of Hathiariari. Hathiariari is located 7

km from the CHC in Poreyahat.

Phool was pregnant with her third child when she died. In 2007 Phool had a C-section to deliver

her first child. Phool delivered her second child at home.

During this pregnancy, Phool went to the ANM at the ICDS twice. She did not report

complications during her pregnancy.

On 17 July 2011 she went into labor so a local midwife came to the house early the next

morning. The child was delivered normally, but Phool had a retained placenta and a post-partum

hemorrhage. The midwife tried to remove the placenta but was unsuccessful. Because of the

complications the family hired a vehicle from Raghunathpur, which reached Sadar hospital

around 7 am on the 18th

July. Phool was pronounced dead on arrival.

Her baby now lives at a missionary orphanage in Bhagalpur, Bihar.

Narrative as told by Raja Marandi, Phool Murmu’s husband.

18. Rekha Devi, age 20

Rekha Devi, wife of Mangalchand Pandit, resided in the village of Pindrahat Mukhiya Tola.

There is a sub centre located in Pindrahat and the CHC for Pindrahat is in Poreyahat.

Rekha Devi was 20 years old and pregnant with her first child when she died. During her

pregnancy she went to the ICDS once to see the ANM who gave her one tetanus injection. She

also visited a private gynaecologist in Godda three times during her pregnancy. She did not have

complications.

On 2 September 2011 she had a normal delivery at her paternal home in Saroni. On 4 September

as she went to sleep she slipped into unconscious. A local practitioner gave her some medicines

and an IV. When her condition did not improve, the family took her to a private clinic at Saroni.

From there she went to Sadar Hospital in Godda. The doctors referred her to Jawaharlal Nehru

Medical College and Hospital (JNCH) in Bhagalpur, Bihar, 70 km away from Godda. At about

11 am on 6 September 2011 Rekha was admitted to JNMCH. She received injections and an IV.

She started having convulsions and frothing from the mouth. Her condition continued to

deteriorate and she finally died at around 3:30 pm on the 6th

.

The family spent about Rs. 4,100 on vehicle hires and Rs. 2,150 on medicines.

Narrative as told by Doman Pandit, Rekha Devi’s father-in-law.

19. Mamita Devi, age 20

Mamita Devi, wife of Munna Singh, (deceased) was a resident of Lucitarn.

Lucitarn’s sub centre is located in Barmasia and Lucitarn is about 15 km from the CHC in

Poreyahat.

Mamita was 20 years old and pregnant for the first time when she died. During her pregnancy

Mamita did not receive antenatal care. Her village does not have an ICDS. The ANM’s in this

part of Jharkhand exclusively operate out of the ICDS centres so villages without centres do not

have access to ANMs. Despite the lack of antenatal care, Mamita reported no complications

during the course of her pregnancy.

On 23 August 2011 Mamita had a normal delivery at home, assisted by a local midwife. There

were no complications reported. On 1 September, about a week after giving birth, Mamita ran

home to avoid a rain storm. When she reached home, she felt a terrible weakness and took a nap.

Gradually she stopped speaking and became unconscious. A local practitioner gave her

injections and an IV. He also advised taking her to Godda as she was in a serious condition.

Before the family could arrange for the money and vehicle she died on 3 September 2011.

Her husband died of a reported paralytic attack and the child died one and a half months after

being born.

As told by residents of Lucitarn

20. Itwarni Paharin, age 19

Itwarni Paharin w/o Kaliya Paharia resided in the village of Tasaria. Itwarni was 19 years old

and pregnant for the second time when she died. Her first pregnancy resulted in a stillbirth in

2009.

From the beginning of this pregnancy, Itwarni reported weakness and swelling in her legs. Six

months into her pregnancy Itwarni visited the CHC in Sundarpahari where she was given Hemfer

Syrup and Vitamin B. Ituri had also taken herbal medicines to reduce her swelling. Itwarni never

received NMBS or JSY money.

At 3 pm on 3 July (9 months into her pregnancy), she had pains that intensified at night.

Because her family had no money, they could not call a vehicle to take her to the hospital. At 2

am her husband left in search of a local midwife but the midwife would not leave her home in

the middle of the night..

Itwarni delivered twins with the assistance of her family members. Thirty minutes later she had

bleeding, breathing problems and intense coughing. At 3 am her husband called a local

practitioner who gave her injections. She died while receiving the injections.

At 1 kg each, the twins were very weak. Another village mother breastfed them, but they both

died on 4 July 2011.

21. Marangmoy Murmu, age 30

Marangmoy Murmu, wife of Madan Hembrom, resided in Simaldhab village. Simaldhab’s sub

centre is located in Bansjori and the CHC is in Sundarpahari.

Marangmoy was 30 years old during her pregnancy. Throughout her pregnancy she had a

chronic fever and headache. She took tablets for her symptoms. After taking the tablets, she had

slow bleeding that eventually stopped. On 1 May 2011 she gave birth to a stillborn baby at home.

Two weeks later a local practitioner treated her for malaria. The practitioner gave her injections

and put her on an IV. Three days later she started bleeding again. The family gave her local

herbal medicines and the bleeding stopped , only to resume the next day.

At 3 am on 25 May the bleeding increased and the family members called for a private vehicle to

take Marangmoy to the hospital. The car arrived six hours later and the family reached Sadar

Hosptial in Godda at 11 am. At Sadar Hospital the doctors administered injections and put her on

an IV. They then referred her to the government hospital Bhagalpur, Bihar for a blood

transfusion. The family was able to arrange for a vehicle by 5 pm and left for Bhagalpur.

Bhagalpur is 70 km away and 13 km into the journey, Marangmoy had difficulty breathing and

died.

The family spent Rs. 4300, including Rs. 2700 on the vehicle, Rs. 1000 on the local practitioner,

and Rs. 600 on medicines.

Marangmoy is survived by her three sons.

22. Kaikeyi Devi

Kaikeyi Devi, wife of Pawan Rai resided in Kamradol. Kamradol’s sub centre is in Tilatanr and

the CHC is in Poreyahat.

During her pregnancy, Kaikeyi complained of weakness and burning. At 12:30 pm on June 2011

during Kaikey’s seventh month, she started bleeding, but no one was home to help. At around 10

pm she consulted a local practitioner who gave her an IV and four injections. The bleeding was

controlled until 6 am the following day. The local practitioner then advised her to go to Bousi in

Bihar.

To arrange for money, the family sold a cow and mortgaged jewelry for Rs. 3,000. Kaikeyi was

put on a pushcart and taken to the main road for the bus to Bousi. At Bousi they consulted a

private doctor who asked them to get Kaikeyi’s blood and urine examined and to get an

ultrasonography. The family took an auto rickshaw 30 km to Banka for the ultrasonography. At

Banka, the doctors told the family to go to Bhagalpur. Bleeding continued. At a private clinic in

Bhagalpur the doctor said that Kaikeyi needed a blood transfusion and that the family should go

to Jawaharlal Nehru Medical College Hospital (JLNCH).

When they reached JLNCH, the doctor examined Kaikeyi, gave her a few injections, and put her

on an IV. The family was asked to arrange for blood and so they got their own blood examined.

Their group did not match Kaikeyi and they could not find blood. Finally, at around 10:00 am on

14 June 2011 they managed to get 1 unit of blood for Rs. 3,000. Halfway through the transfusion

Kaikeyi began to have breathlessness and was given oxygen. She died an hour later at 3 pm.

The family spent about Rs. 7,000 for care and transportation.

23. Sonamuni Hansda

Sonamuni Hansda, wife of Bishnu Murmu, resided in Balathar. Balathar’s sub health centre is in

Beldang and their CHC is in Poreyahat.

On the evening of 18 June 2011 Sonamuni Hansda started having labor pains. At 2 am the pains

became unbearable and Sonamuni’s husband, Bishnu, went to the ASHA. The ASHA called a

private vehicle that reached the hospital at 6 a.m. on 19 June. On reaching the hospital the ANM,

Helen Murmu, took Sonamuni to the labor room and asked the ASHA to get the doctor to

conduct an examination. Later an ANM named Vinita Kumara told the family that an injection

would have to be administered for delivery. The family had to give the ANM Rs. 300 for the

injection. Delivery did not take place until 9 am by which time ANM Vinita Kumari had left.

The labor pains again intensified and Sonamuni’s mother-in-law went to call ANM Surajmuni

who demanded Rs. 600 for conducting the delivery. She said she would not conduct the delivery

until she had received Rs. 600. The family finally gave Rs. 500 for conducting a delivery,

another injection was administered, and the delivery took place by 11:45 am.

The child was born very weak and did not initially cry or breathe. However, eventually the baby

began to breathe with difficulty. Two hours after delivery the ANM asked the family to go home.

The baby would not breastfeed and died at 9 pm on 20 June 2011.

24. BS, age 21

BS, wife of AM, resided in Bara Mahuantar village.

Bara Mahuantar is 2.5 km away from a sub centre and 15 km from the community health centre in

Sundarpahari.

BS was 21 and pregnant with her first child when she died. During her pregnancy she had reported no

problems or complications. She received 2 Tetanus injections from ICDS at Bara Mahuatanr. She was

never given Iron/ Folic Acid tablets nor was she ever examined by the ANM or visited by the ANM in her

home.

At 4 am on 22 January 2012, BS went into labour. A traditional dai from a neighbouring village told the

family the child would arrive at any minute. A local practitioner gave BS an IV in the left hand. Half way

through the IV, her hand started swelling, so the local practitioner moved the IV to her right hand. Her

right hand also swelled, so the local practitioner moved the IV to her palm. Throughout all of this, BS

reported a burning sensation and pain from the IV.

By 9 am she slipped into unconscious. An ambulance arrived from Ghatiari at about 9:30 am (Ghatiari is

just 2 km away with good road connections). The husband of the ANM of Ghatiari HSC owns the

vehicle.

BS was first taken to CHC-Sundarpahari and then referred to Sadar Hospital-Godda where she was

declared dead on arrival.

The ambulance charged the family Rs 400 for fuel.

Reports from Interviews with ASHAs

The team spoke with an ASHA who had been working in her village for six months. She did not

have a medicine kit. She had a one-day training on nutrition and maternal health. She said that

the ANM came to her village twice to administer injections, but few people attended. No Iron/

Folic Acid tablets have been given to the pregnant women in her village. The ASHA said she

understood her responsibilities as keeping the village clean and sanitized, accompanying

pregnant women to the hospital, and giving medicine to TB patients. She said she has sprayed

DDT around the village and kept the main road clean as a part of her duties.

Another ASHA from a village with an ICDS centre says that the ANM’s attendance is sporadic.

She says that no NMBS or JSY money is distributed to women. She says pregnant women and

children go about to the centre about times a year. This ASHA said she was appointed in 2007

but was not trained or told what her duties were until 2010. Although she has officially been an

ASHA since 2007, she has no medical kit but has recently been given birth control pills to give

to women in the village. Aside from the contraceptive pills, the only resources she has are a

thermometer and a book. She reported that the ANM has never visited the pregnant women in

the village and only operates out of the ICDS.

The ASHA also said that iron/folic acid tablets have not been distributed for two years and the

ANM only gives tetanus injections and does not perform physical injections. The ANM lives in

Godda and comes to the village in the morning.

The ASHA said one woman in her village who has seven living children was nine months

pregnant with her eleventh pregnancy. The woman has received no TT injections, has never been

examined by the ANM and has received no iron folic acid tablet.

Many of the ASHAs reported that it was difficult to convince women to go to the hospital for

delivery because they do not feel comfortable in public health facilities.

Based on the facts gathered and visits to the various health centres in Godda district the fact-

finders determined this to be a reasonable and even justifiable fear.