Express delivery in India’s Madhya Pradesh

Sitting on the floor of her village homestead in India’s Madhya Pradesh region and cradling her new born baby girl in her arms, 27-year-old Asha Jatav is all smiles.

Two days ago, Asha had leant heavily on her mother-in-law’s shoulders as she was carefully lowered into the back of the Janani Express.

Named after the Hindi word for mother, the Janani is a free ambulance service taking pregnant women to government hospitals and community health centres in rural India.

The service is part of Madhya Pradesh’s Health Sector Reform programme, part funded by DFID.

It was Asha’s first ride in the Janani Express. Three years ago, when she had her first child, the service did not exist.

Crucially, the service means that mothers and babies can get skilled help at a health centre if they develop problems and information on breastfeeding and baby care from health workers.

Asha’s 27 km journey to Shivpuri district hospital took her over narrow, cobbled lanes with deep ruts left by last season’s rains, escorted by groups of curious children along the way.

In Shivpuri district, the Janani Express has boosted child deliveries in hospitals and health centres. It is now used by 30% of rural institutions and its popularity is growing. Since its launch in September 2008, the Janani’s call centre at Shivpuri has taken more than 10,000 calls - or 900 a month - of which only 574 have been referred.

“We can reach nearly everyone. Only occasionally do the villagers need to get the tractor out to meet us”, says the driver, Mukesh.

The service’s vehicles may be basic - the same two-wheel-drive Suzuki more commonly used as Indian taxis - but Asha has nothing but praise for the experience.

“I was very happy with the Janani Express. The sarpanch (village head) couldn’t find anyone to take me to hospital for my first child so I had to have the baby at home and it didn’t feel as safe.”

Not all Janani passengers are so lucky. Anita lives only 10 kilometres from the district hospital but was forced to deliver her baby before she arrived.

On average, one in 20 women give birth during their journey and Mukesh has seen 25 babies born in his two-year stint behind the wheel.

Sexual politics within a typical rural Indian family dictate that the woman first seeks permission of the man before they can call for the service.

Often the decision to take her to a clinic is taken at the last moment, leaving very little time in an emergency.

Fortunately for Anita, the birth was problem free.

Rekha Rawat, a respected accredited social health activist (ASHA) was on hand to assist.

“I’m used to it now but it is not a situation I like to find myself in, as it places the wellbeing of the mother and baby at much greater risk if things don’t go smoothly.”

The ASHAs are recruited from the villages they serve. They visit expectant mothers, persuading them of the benefits of a clinic birth over one at home and give advice on immunisation, sanitation and nutrition for themselves and their baby.

Financial incentives also play a part.

On leaving the health centres, mothers receive a cheque for 1400 rupees to cover lost days’ work and expenses, as part of the DFID-supported Reproductive and Child Health programme. The ASHAs also get 350 rupees for their part in the service.

Asha fawns over her new baby daughter while her mother-in-law looks on proudly.

On being asked what she will do with the money she’s received, Asha replies, “I’m going to buy some warm clothes for the baby and some household items.”

Nothing for herself? “Well, I’ll make some ladoos (a sweet sugary snack). That’ll be my treat”, she giggles.

Facts and stats

DFID’s state level programmes in Madhya Pradesh began in 1999 and it is the state’s biggest bilateral donor (programme spend for 2008/09 was £30m).

Madhya Pradesh’s health programme (£60 million from 2007-2012) helps the government of Madhya Pradesh implement a comprehensive state-wide health strategy.

DFID also supports the central government of India’s Reproductive and Child Health programme (£252 million over 2005-2010) which has trained over 40,000 ASHA workers in Madhya Pradesh and provides the cash incentive for women who give birth in a health facility.

Use of emergency and ambulance transport for pregnant mothers has increased from less than 1% of deliveries in 2006-07 to 30% today. This, along with cash incentives from the government, contributed to doubling of births in health facilities from half a million in 2006 to over a million in 2009.

Safe delivery and newborn care is contributing to a reduction in infant mortality, which dropped by 14% from 79 to 70 per thousand in Madhya Pradesh during the same period.

In Madhya Pradesh 17 women die every day in child birth. In India a woman dies every 7 minutes in childbirth.